Provider Demographics
NPI:1366999153
Name:SHAH, MANAN (MD)
Entity type:Individual
Prefix:DR
First Name:MANAN
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 FOLTIM WAY
Mailing Address - Street 2:
Mailing Address - City:CONGERS
Mailing Address - State:NY
Mailing Address - Zip Code:10920-1424
Mailing Address - Country:US
Mailing Address - Phone:845-267-8669
Mailing Address - Fax:
Practice Address - Street 1:41 WILSON AVE
Practice Address - Street 2:SUITE 2D
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105
Practice Address - Country:US
Practice Address - Phone:973-589-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA11135300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program