Provider Demographics
NPI:1750376141
Name:SHANKER, MUKESH JAY (MD)
Entity type:Individual
Prefix:DR
First Name:MUKESH
Middle Name:JAY
Last Name:SHANKER
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 1201
Mailing Address - Street 2:
Mailing Address - City:ABSECON
Mailing Address - State:NJ
Mailing Address - Zip Code:08201-5201
Mailing Address - Country:US
Mailing Address - Phone:609-653-1611
Mailing Address - Fax:609-653-9352
Practice Address - Street 1:2106 NEW RD
Practice Address - Street 2:STE E-4
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1046
Practice Address - Country:US
Practice Address - Phone:609-653-1611
Practice Address - Fax:609-653-9352
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04670800207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ222928205OtherHORIZON
NJ43283OtherHEALTHCARE AETNA
NJ0116086000OtherAMERIHEALTH
540960Medicare ID - Type Unspecified
D19606Medicare UPIN