Healthcare Provider Details

I. General information

NPI: 1790282507
Provider Name (Legal Business Name): JESHAL MISTRY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 EASTON RD
WILLOW GROVE PA
19090-1901
US

IV. Provider business mailing address

5-15 ASPEN WAY
DOYLESTOWN PA
18901-2780
US

V. Phone/Fax

Practice location:
  • Phone: 215-830-5400
  • Fax:
Mailing address:
  • Phone: 267-615-1526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC015611
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: