Provider Demographics
NPI:1124431622
Name:VISHWAKARMA, MUKUL
Entity type:Individual
Prefix:
First Name:MUKUL
Middle Name:
Last Name:VISHWAKARMA
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 1:9 HOLMES AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-6509
Mailing Address - Country:US
Mailing Address - Phone:201-844-5142
Mailing Address - Fax:
Practice Address - Street 1:377 JERSEY AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302
Practice Address - Country:US
Practice Address - Phone:201-499-3891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01479300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist