Provider Demographics
NPI:1891740080
Name:SHAH, REZA ALI (DO)
Entity Type:Individual
Prefix:DR
First Name:REZA
Middle Name:ALI
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3444
Mailing Address - Street 2:
Mailing Address - City:MERCERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-0444
Mailing Address - Country:US
Mailing Address - Phone:609-586-9788
Mailing Address - Fax:609-586-1323
Practice Address - Street 1:2063 KLOCKNER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-3414
Practice Address - Country:US
Practice Address - Phone:609-586-9788
Practice Address - Fax:609-586-1232
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB067647002086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2690963000OtherAMERIHEALTH
NJ3K2190OtherHEALTHNET
NJ5727757OtherAETNA
NJ7180223002OtherCIGNA
NJP1626337OtherOXFORD
NJ7947801Medicaid
NJ203985484OtherTAX ID
NJ2039854840OtherHORIZON
NJ60032148OtherHORIZON NJ HEALTH
NJ7279755OtherUNITED HEALTHCARE
NJ7947801Medicaid
NJ100948Medicare PIN