Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 25MA07930800 | NJ |
Y | 111NI0900X | Internist | 25MA07930800 | NJ |
N | 208D00000X | General Practice Physician | 25MA07930800 | NJ |
NPI | 1053302976 |
---|---|
Provider Name | Dr. Tusharkumar N Mistry |
First Address | Old Bridge, NJ 08857-2558 |
Second Address | Old Bridge, NJ 08857-2558 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2005 |
Last Update Date | 21/06/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0075850 | (05) | NJ |
I39199 | (02) | NJ |