Provider Demographics
NPI:1205362225
Name:PATEL, PUJA (OD)
Entity Type:Individual
Prefix:
First Name:PUJA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1038 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-3407
Mailing Address - Country:US
Mailing Address - Phone:718-328-7137
Mailing Address - Fax:
Practice Address - Street 1:1038 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459
Practice Address - Country:US
Practice Address - Phone:718-328-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYTUV008817152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program