Provider Demographics
NPI:1851345995
Name:MAVASHEVA, SOFIA
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:MAVASHEVA
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 1:2055 KLOCKNER RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-3413
Mailing Address - Country:US
Mailing Address - Phone:609-586-8060
Mailing Address - Fax:609-586-7470
Practice Address - Street 1:2055 KLOCKNER RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-3413
Practice Address - Country:US
Practice Address - Phone:609-586-8060
Practice Address - Fax:609-586-7470
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07092800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH26827Medicare UPIN
NJ043145L5EMedicare ID - Type Unspecified