Provider Demographics
NPI:1912925769
Name:SHAGAN, BERNARD PELLMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:PELLMAN
Last Name:SHAGAN
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 1:255 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6214
Mailing Address - Country:US
Mailing Address - Phone:732-222-5200
Mailing Address - Fax:732-741-3082
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-222-5200
Practice Address - Fax:732-741-3082
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA49925207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2387300Medicaid
NJ2387300Medicaid
SH440569Medicare ID - Type Unspecified