Provider Demographics
NPI:1902097264
Name:BORKAR, MANGESH RAJAN
Entity type:Individual
Prefix:
First Name:MANGESH
Middle Name:RAJAN
Last Name:BORKAR
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 1:67100 DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4148
Mailing Address - Country:US
Mailing Address - Phone:317-902-5666
Mailing Address - Fax:
Practice Address - Street 1:67100 DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:317-902-5666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009211A225100000X
NY029068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNAMedicaid