Provider Demographics
NPI:1790451797
Name:BHAVSAR, POONAM K
Entity type:Individual
Prefix:DR
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 1:5917 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-1306
Mailing Address - Country:US
Mailing Address - Phone:201-861-0016
Mailing Address - Fax:218-617-7303
Practice Address - Street 1:5917 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1306
Practice Address - Country:US
Practice Address - Phone:201-861-0016
Practice Address - Fax:218-617-7303
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OM00174900152W00000X
NJ27OA00707600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist