Provider Demographics
NPI:1669407375
Name:MIRMANESH, SHAPOUR STEVE (MD)
Entity type:Individual
Prefix:
First Name:SHAPOUR
Middle Name:STEVE
Last Name:MIRMANESH
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 1:5120 NEW HAMPSHIRE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08037
Mailing Address - Country:US
Mailing Address - Phone:856-985-0203
Mailing Address - Fax:856-985-0010
Practice Address - Street 1:12000 LINCOLN DRIVE WEST
Practice Address - Street 2:SUITE 405
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-0203
Practice Address - Fax:856-985-0010
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07725100208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0033189Medicaid
NJ0033189Medicaid