=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457812273
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE DEVANAND NAIDOO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2019
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 JAMES ST
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08820-3947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-321-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 634575
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-4575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 889-526-7728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD26260
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 25MA12413100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------