Provider Demographics
NPI:1962077032
Name:SHRESTHA, PRAYANK (DPM)
Entity type:Individual
Prefix:DR
First Name:PRAYANK
Middle Name:
Last Name:SHRESTHA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HAMBURG TPKE STE 108
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2033
Mailing Address - Country:US
Mailing Address - Phone:973-925-4111
Mailing Address - Fax:
Practice Address - Street 1:510 HAMBURG TPKE STE 108
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2033
Practice Address - Country:US
Practice Address - Phone:973-925-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP1100X
NJ25MD00383400213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric