Healthcare Provider Details

I. General information

NPI: 1932269982
Provider Name (Legal Business Name): SHIVA GOPAL VASISHTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 EVESHAM ROAD PAVILION 800 SUITE 209
VOORHEES NJ
08043
US

IV. Provider business mailing address

2301 EVESHAM ROAD PAVILION 800 SUITE 209
VOORHEES NJ
08043
US

V. Phone/Fax

Practice location:
  • Phone: 856-651-0060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number25MA55133
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: