Provider Demographics
NPI:1891252748
Name:SHAH, POORNA BHASKAR
Entity Type:Individual
Prefix:DR
First Name:POORNA
Middle Name:BHASKAR
Last Name:SHAH
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 1:1070 CLIFTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3619
Mailing Address - Country:US
Mailing Address - Phone:973-246-6565
Mailing Address - Fax:973-883-0140
Practice Address - Street 1:1070 CLIFTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3619
Practice Address - Country:US
Practice Address - Phone:973-246-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01579900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist