Provider Demographics
NPI:1417696345
Name:ELIAVA, SHALVA (MD)
Entity type:Individual
Prefix:
First Name:SHALVA
Middle Name:
Last Name:ELIAVA
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 1:350 ENGLE STREET, DEPARTMENT OF MEDICINE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-894-3143
Mailing Address - Fax:
Practice Address - Street 1:350 ENGLE STREET, DEPARTMENT OF MEDICINE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-894-3143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2025-06-20
Deactivation Date:2023-02-27
Deactivation Code:
Reactivation Date:2023-03-08
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA12618900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program