Provider Demographics
NPI:1790451797
Name:BHAVSAR, POONAM K
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:K
Last Name:BHAVSAR
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 1:485 ROUTE 1 SOUTH
Mailing Address - Street 2:BUILDING A
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:485 ROUTE 1 SOUTH
Practice Address - Street 2:BUILDING A
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830
Practice Address - Country:US
Practice Address - Phone:732-750-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OM00174900152W00000X
NJ27OA00707600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist