Provider Demographics
NPI:1922095348
Name:HABEEBULLA, SHAJI (MD)
Entity Type:Individual
Prefix:
First Name:SHAJI
Middle Name:
Last Name:HABEEBULLA
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:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:8 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060
Practice Address - Country:US
Practice Address - Phone:603-577-2045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228646207R00000X
NH18734207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2005794Medicaid
H84888Medicare UPIN
MAA35363Medicare ID - Type Unspecified