Provider Demographics
NPI:1295049039
Name:SHAH, PURVIBEN (MD)
Entity type:Individual
Prefix:
First Name:PURVIBEN
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 KNIGHTSBRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-1271
Mailing Address - Country:US
Mailing Address - Phone:609-713-8509
Mailing Address - Fax:
Practice Address - Street 1:175 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-2038
Practice Address - Country:US
Practice Address - Phone:609-261-7486
Practice Address - Fax:609-914-6182
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08773800207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0238775Medicaid
NJ190725YBAWMedicare PIN