Provider Demographics
NPI:1003631755
Name:NAGARWALA, MATHURA
Entity type:Individual
Prefix:
First Name:MATHURA
Middle Name:
Last Name:NAGARWALA
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 1:877 BRUCKNER BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-5201
Mailing Address - Country:US
Mailing Address - Phone:917-714-0067
Mailing Address - Fax:
Practice Address - Street 1:877 BRUCKNER BLVD FL 3
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-5201
Practice Address - Country:US
Practice Address - Phone:917-714-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYCPS-P-76134175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist