=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104368034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAHENDRA M PUJARA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2016
-----------------------------------------------------
Last Update Date | 11/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1630 MOUNT HOPE AVE
-----------------------------------------------------
City | POTTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17901-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-622-1553
-----------------------------------------------------
Fax | 570-622-3531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1630 MOUNT HOPE AVE
-----------------------------------------------------
City | POTTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17901-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-622-1553
-----------------------------------------------------
Fax | 570-622-3531
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FRONT OFFICE
-----------------------------------------------------
Name | JARRET PAULY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-622-1553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD03778OL
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------