Basic Information
Provider Information
NPI: 1003152265
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SHAH
FirstName: VIDISHA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: MPT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 610 WASHINGTON BLVD
Address2:  
City: JERSEY CITY
State: NJ
PostalCode: 073101400
CountryCode: US
TelephoneNumber: 6262023596
FaxNumber:  
Practice Location
Address1: 610 WASHINGTON BLVD
Address2:  
City: JERSEY CITY
State: NJ
PostalCode: 073101400
CountryCode: US
TelephoneNumber: 2122273233
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/17/2012
LastUpdateDate: 03/05/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/05/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X40QA01599200NJY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X035781NYN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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