Provider Demographics
NPI:1831258607
Name:SHAH, DEEPAK O (MD)
Entity type:Individual
Prefix:DR
First Name:DEEPAK
Middle Name:O
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 947
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-0947
Mailing Address - Country:US
Mailing Address - Phone:201-792-2727
Mailing Address - Fax:201-653-3420
Practice Address - Street 1:142 PALISADE AVE STE 103
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1108
Practice Address - Country:US
Practice Address - Phone:201-792-2727
Practice Address - Fax:201-653-3420
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA36851207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ178125OtherPTAN
NJ0578703Medicaid
NJC53737Medicare UPIN