Provider Demographics
NPI:1700101235
Name:SURYAWANSHI, JIWAJIRAO GULABRAO
Entity Type:Individual
Prefix:MR
First Name:JIWAJIRAO
Middle Name:GULABRAO
Last Name:SURYAWANSHI
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 1:5 DOREEN CT
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-2202
Mailing Address - Country:US
Mailing Address - Phone:973-784-3085
Mailing Address - Fax:
Practice Address - Street 1:5 DOREEN CT
Practice Address - Street 2:
Practice Address - City:ROCKAWAY
Practice Address - State:NJ
Practice Address - Zip Code:07866-2202
Practice Address - Country:US
Practice Address - Phone:973-784-3085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-27
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043558-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist