Provider Demographics
NPI:1881974574
Name:SHAH, KAVITHA (MD)
Entity type:Individual
Prefix:DR
First Name:KAVITHA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KAVITHA
Other - Middle Name:
Other - Last Name:SEBAMALAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1135 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3346
Mailing Address - Country:US
Mailing Address - Phone:973-754-4100
Mailing Address - Fax:
Practice Address - Street 1:1135 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3346
Practice Address - Country:US
Practice Address - Phone:973-754-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09499600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program