Basic Information
| Provider Information | |||||||||
| NPI: | 1629206875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHETAL MANSURIA MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2107 | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070397707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735353800 | ||||||||
| FaxNumber: | 9735353808 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 OLD SHORT HILLS RD | ||||||||
| Address2: | SUITE 213 | ||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070395604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735353800 | ||||||||
| FaxNumber: | 9735353808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 06/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | MANSURIA | ||||||||
| AuthorizedOfficialFirstName: | SHETAL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9732942212 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MA71413 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 064937 | 01 | NJ | MEDICARE, TYPE UNSPECIFIED | OTHER |