Provider Demographics
NPI:1629170295
Name:MISTRY, MEHERWAN JAMSHED (MD)
Entity Type:Individual
Prefix:DR
First Name:MEHERWAN
Middle Name:JAMSHED
Last Name:MISTRY
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 1:402 DELAWARE DR
Mailing Address - Street 2:
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-1058
Mailing Address - Country:US
Mailing Address - Phone:570-491-4159
Mailing Address - Fax:
Practice Address - Street 1:402 DELAWARE DR
Practice Address - Street 2:
Practice Address - City:MATAMORAS
Practice Address - State:PA
Practice Address - Zip Code:18336-1058
Practice Address - Country:US
Practice Address - Phone:570-491-4159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128983-1208600000X
PAMD021779E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY28A041Medicare ID - Type Unspecified
A61794Medicare UPIN
PAMI107796Medicare ID - Type Unspecified