Healthcare Provider Details

I. General information

NPI: 1689154106
Provider Name (Legal Business Name): DR. SUKETU PATHAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 PARK AVE
PLAINFIELD NJ
07060-1612
US

IV. Provider business mailing address

103 MARTIN AVE
CLIFTON NJ
07012-1108
US

V. Phone/Fax

Practice location:
  • Phone: 570-630-5085
  • Fax:
Mailing address:
  • Phone: 973-979-4930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03935100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: