Provider Demographics
NPI:1952371924
Name:PUJARA, MAHENDRA M (MD)
Entity Type:Individual
Prefix:
First Name:MAHENDRA
Middle Name:M
Last Name:PUJARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-1337
Mailing Address - Country:US
Mailing Address - Phone:570-622-1553
Mailing Address - Fax:570-622-3531
Practice Address - Street 1:1630 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-1337
Practice Address - Country:US
Practice Address - Phone:570-622-1553
Practice Address - Fax:570-622-3531
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037780L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000831495001Medicaid
PAC32312Medicare UPIN
PAPU160112Medicare ID - Type Unspecified