Provider Demographics
NPI:1053411272
Name:SHEN, JUNG SAN (MD)
Entity type:Individual
Prefix:
First Name:JUNG
Middle Name:SAN
Last Name:SHEN
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 1:219 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3453
Mailing Address - Country:US
Mailing Address - Phone:908-352-5927
Mailing Address - Fax:908-352-6181
Practice Address - Street 1:219 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-3453
Practice Address - Country:US
Practice Address - Phone:908-352-5927
Practice Address - Fax:908-352-6181
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02834800207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2112701Medicaid
NJC57906Medicare UPIN
NJ2112701Medicaid