Provider Demographics
NPI:1851304299
Name:SHAKARSHY, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SHAKARSHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 W JIMMIE LEEDS RD
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9406
Mailing Address - Country:US
Mailing Address - Phone:609-677-9729
Mailing Address - Fax:609-652-7153
Practice Address - Street 1:72 W JIMMIE LEEDS RD
Practice Address - Street 2:SUITE 1100
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9406
Practice Address - Country:US
Practice Address - Phone:609-677-9729
Practice Address - Fax:609-652-7153
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA053045002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ300081010OtherRAILROAD MEDICARE
NJ5002907Medicaid
NJP00847825OtherRAILROAD MEDICARE
NJP00758322OtherRAILROAD MEDICARE
NJP00758322OtherRAILROAD MEDICARE
NJE75321Medicare UPIN
NJ5002907Medicaid
NJ405614ZDDPMedicare PIN