Healthcare Provider Details

I. General information

NPI: 1851333793
Provider Name (Legal Business Name): AJIT M. SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 BELLEVILLE AVE
BLOOMFIELD NJ
07003-3589
US

IV. Provider business mailing address

206 BELLEVILLE AVE
BLOOMFIELD NJ
07003-3589
US

V. Phone/Fax

Practice location:
  • Phone: 973-566-9900
  • Fax: 973-566-6692
Mailing address:
  • Phone: 973-566-9900
  • Fax: 973-566-6692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA02998200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2884801
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: