Provider Demographics
NPI:1588922926
Name:MAVANI, PRATIK MANSUKH
Entity type:Individual
Prefix:DR
First Name:PRATIK
Middle Name:MANSUKH
Last Name:MAVANI
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 1:13 BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-6660
Mailing Address - Country:US
Mailing Address - Phone:973-262-2764
Mailing Address - Fax:
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:SUITE 1099J
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-6028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY2931522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program