Healthcare Provider Details

I. General information

NPI: 1548756786
Provider Name (Legal Business Name): DAVID SHAKER DO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 SUMMIT AVE
HACKENSACK NJ
07601-1263
US

IV. Provider business mailing address

38 SUMMIT AVE
HACKENSACK NJ
07601-1263
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-6360
  • Fax:
Mailing address:
  • Phone: 201-343-6360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number25BM10243200
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DAVID SHAKER
Title or Position: OWNER
Credential: DO
Phone: 201-343-6360