Healthcare Provider Details

I. General information

NPI: 1750376141
Provider Name (Legal Business Name): MUKESH JAY SHANKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 NEW RD STE E-4
LINWOOD NJ
08221-1046
US

IV. Provider business mailing address

PO BOX 1201
ABSECON NJ
08201-5201
US

V. Phone/Fax

Practice location:
  • Phone: 609-653-1611
  • Fax: 609-653-9352
Mailing address:
  • Phone: 609-653-1611
  • Fax: 609-653-9352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA04670800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: