Provider Demographics
NPI:1679505325
Name:MIRMANESH, SHAHIN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHIN
Middle Name:MICHAEL
Last Name:MIRMANESH
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 1:1 STAR SPLITTER CT
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-9517
Mailing Address - Country:US
Mailing Address - Phone:856-985-0203
Mailing Address - Fax:856-985-0010
Practice Address - Street 1:12000 LINCOLN DR W
Practice Address - Street 2:SUITE 405
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3402
Practice Address - Country:US
Practice Address - Phone:856-985-0203
Practice Address - Fax:856-985-0010
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06992000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8584800Medicaid
NJ8584800Medicaid
NJH04331Medicare UPIN