Provider Demographics
NPI:1457368680
Name:PATEL, SHODHAN (MD)
Entity Type:Individual
Prefix:
First Name:SHODHAN
Middle Name:
Last Name:PATEL
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 1:1450 PARKSIDE AVE
Mailing Address - Street 2:5
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08638
Mailing Address - Country:US
Mailing Address - Phone:609-771-1881
Mailing Address - Fax:609-538-0177
Practice Address - Street 1:1450 PARKSIDE AVE
Practice Address - Street 2:5
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08638
Practice Address - Country:US
Practice Address - Phone:609-771-1881
Practice Address - Fax:609-538-0177
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06665200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI000053103OtherAMERICHOICE
0468023000OtherKEYSTONE
P2552484OtherOXFORD
NJ7442408Medicaid
G65674Medicare UPIN
NJ002680P3LMedicare ID - Type Unspecified