Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 25MA11088200 | NJ |
Y | 111NI0900X | Internist | 25MA11088200 | NJ |
NPI | 1003304940 |
---|---|
Provider Name | Roshan Sureshchandra Shah |
First Address | Neptune, NJ 07753-2645 |
Second Address | Hackensack, NJ 07601-1915 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/04/2018 |
Last Update Date | 10/08/2021 |