Healthcare Provider Details

I. General information

NPI: 1629867890
Provider Name (Legal Business Name): S. PATHARE, M.D., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 JEWETT AVE
STATEN ISLAND NY
10302-2654
US

IV. Provider business mailing address

565 JEWETT AVE
STATEN ISLAND NY
10302-2654
US

V. Phone/Fax

Practice location:
  • Phone: 718-701-6010
  • Fax:
Mailing address:
  • Phone: 718-701-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAILESH PATHARE
Title or Position: OWNER
Credential: MD
Phone: 718-701-6010