Provider Demographics
NPI:1972871598
Name:PHADKE, SHIVAJI GAJANAN
Entity type:Individual
Prefix:
First Name:SHIVAJI
Middle Name:GAJANAN
Last Name:PHADKE
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 1:113 W KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3902
Practice Address - Country:US
Practice Address - Phone:718-432-3180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03281000183500000X
NY057972183500000X
PARP441450183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist