Healthcare Provider Details

I. General information

NPI: 1871596387
Provider Name (Legal Business Name): SUSHEEL BATHLA DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 EDISON ST
STATEN ISLAND NY
10306-3041
US

IV. Provider business mailing address

172 DEER RUN
WATCHUNG NJ
07069-6222
US

V. Phone/Fax

Practice location:
  • Phone: 718-524-4112
  • Fax: 718-524-4189
Mailing address:
  • Phone: 718-524-4112
  • Fax: 718-524-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN005417
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: