Provider Demographics
NPI:1629638234
Name:PANCHAL, MAYURI ASHOK
Entity Type:Individual
Prefix:
First Name:MAYURI
Middle Name:ASHOK
Last Name:PANCHAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 PATERSON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-3424
Mailing Address - Country:US
Mailing Address - Phone:909-498-6720
Mailing Address - Fax:
Practice Address - Street 1:266 HARRISTOWN RD STE 304
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3321
Practice Address - Country:US
Practice Address - Phone:201-345-5905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01859400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist