Healthcare Provider Details

I. General information

NPI: 1639793540
Provider Name (Legal Business Name): SHIVANI KHETANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22-18 BROADWAY STE 201
FAIR LAWN NJ
07410-3016
US

IV. Provider business mailing address

1225 MCBRIDE AVE
WOODLAND PARK NJ
07424-3812
US

V. Phone/Fax

Practice location:
  • Phone: 862-297-9696
  • Fax:
Mailing address:
  • Phone: 973-812-0377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberUTRESIDENT
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MA12757900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: