Basic Information
| Provider Information | |||||||||
| NPI: | 1538154307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIVENDRA | ||||||||
| FirstName: | SHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 94 OLD SHORT HILLS RD | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070395672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2013225000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA06930200 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 25MA06930200 | NJ | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 8222801 | 05 | NJ | MEDICAID |