Provider Demographics
NPI:1417351164
Name:MISTRY, DAVE
Entity Type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:MISTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1144
Mailing Address - Country:US
Mailing Address - Phone:973-564-9559
Mailing Address - Fax:973-564-9717
Practice Address - Street 1:194 MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1144
Practice Address - Country:US
Practice Address - Phone:973-564-9559
Practice Address - Fax:973-564-9717
Is Sole Proprietor?:No
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01563500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist