Healthcare Provider Details

I. General information

NPI: 1356965057
Provider Name (Legal Business Name): ISHAN POUDEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date: 01/18/2022
Reactivation Date: 02/02/2022

III. Provider practice location address

703 MAIN ST
PATERSON NJ
07503-2621
US

IV. Provider business mailing address

703 MAIN ST
PATERSON NJ
07503-2621
US

V. Phone/Fax

Practice location:
  • Phone: 973-754-2510
  • Fax:
Mailing address:
  • Phone: 973-754-2510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA12807400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: