Provider Demographics
NPI:1538154307
Name:SIVENDRA, SHAN (MD)
Entity type:Individual
Prefix:DR
First Name:SHAN
Middle Name:
Last Name:SIVENDRA
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 1:66 W GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:732-212-0060
Mailing Address - Fax:
Practice Address - Street 1:94 OLD SHORT HILLS RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5672
Practice Address - Country:US
Practice Address - Phone:201-322-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06930200207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8222801Medicaid
NJ033812TS6Medicare PIN
NJH07358Medicare UPIN
NJ8222801Medicaid