Healthcare Provider Details

I. General information

NPI: 1780697490
Provider Name (Legal Business Name): MANOUCHEHR T SHAHAB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CENTRAL AVE
MIDLAND PARK NJ
07432
US

IV. Provider business mailing address

33 CENTRAL AVE
MIDLAND PARK NJ
07432
US

V. Phone/Fax

Practice location:
  • Phone: 201-689-0800
  • Fax: 201-689-0871
Mailing address:
  • Phone: 201-689-0800
  • Fax: 201-689-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number25MA04825700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMA02694700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA02694700
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA04825700
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number25MA04825700
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA02694700
License Number StateNJ
# 7
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMA02694700
License Number StateNJ
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA02694700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: