Healthcare Provider Details

I. General information

NPI: 1659767143
Provider Name (Legal Business Name): PRASHANT BHOOLA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 MONROE ST
BRIDGEWATER NJ
08807-3043
US

IV. Provider business mailing address

9 MONROE ST
BRIDGEWATER NJ
08807-3043
US

V. Phone/Fax

Practice location:
  • Phone: 908-231-1114
  • Fax:
Mailing address:
  • Phone: 908-231-1114
  • Fax: 908-252-1930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00342500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: