Provider Demographics
NPI:1750612131
Name:SHUBHAKAR, VISHWANATH (MD)
Entity type:Individual
Prefix:
First Name:VISHWANATH
Middle Name:
Last Name:SHUBHAKAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VISHU
Other - Middle Name:
Other - Last Name:SHUBHAKAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PRACTICE ASSOCIATES MEDICAL
Mailing Address - Street 2:P.O. BOX 416457
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:973-290-7495
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-290-7495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08814700207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0240575Medicaid