Provider Demographics
NPI:1689154106
Name:PATHAK, SUKETU
Entity Type:Individual
Prefix:DR
First Name:SUKETU
Middle Name:
Last Name:PATHAK
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 1:103 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1108
Mailing Address - Country:US
Mailing Address - Phone:973-979-4930
Mailing Address - Fax:
Practice Address - Street 1:611 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-1612
Practice Address - Country:US
Practice Address - Phone:570-630-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03935100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist