Healthcare Provider Details

I. General information

NPI: 1518055896
Provider Name (Legal Business Name): JONATHAN B SHAMMASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE STE 204
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

385 PROSPECT AVE STE 204
HACKENSACK NJ
07601-2570
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-9150
  • Fax: 551-996-9144
Mailing address:
  • Phone: 551-996-9150
  • Fax: 551-996-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number206910
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08593400
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier01771219
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: