Provider Demographics
NPI:1932269982
Name:VASISHTA, SHIVA GOPAL (MD)
Entity Type:Individual
Prefix:
First Name:SHIVA
Middle Name:GOPAL
Last Name:VASISHTA
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 1:2301 EVESHAM ROAD
Mailing Address - Street 2:PAVILION 800 SUITE 209
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 EVESHAM ROAD
Practice Address - Street 2:PAVILION 800 SUITE 209
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:856-651-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA551332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
584987NVSMedicare PIN
D87840Medicare UPIN