Provider Demographics
NPI:1780697490
Name:SHAHAB, MANOUCHEHR T (MD)
Entity type:Individual
Prefix:DR
First Name:MANOUCHEHR
Middle Name:T
Last Name:SHAHAB
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 1:33 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07432
Mailing Address - Country:US
Mailing Address - Phone:201-689-0800
Mailing Address - Fax:201-689-0871
Practice Address - Street 1:33 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432
Practice Address - Country:US
Practice Address - Phone:201-689-0800
Practice Address - Fax:201-689-0871
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04825700207RA0201X, 2085R0202X, 2085U0001X
NJMA02694700207V00000X, 208VP0000X, 207Q00000X
NJ25MA02694700208100000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
109953Medicare ID - Type Unspecified
D06197Medicare UPIN