1831196278 NPI number — KALYANI I GARDILLA MD

Table of content: KALYANI I GARDILLA MD (NPI 1831196278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831196278 NPI number — KALYANI I GARDILLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDILLA
Provider First Name:
KALYANI
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831196278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RED BANK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07701-0249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-741-3600
Provider Business Mailing Address Fax Number:
732-741-6079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 HARTFORD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TINTON FALLS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07701-4929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-741-3600
Provider Business Practice Location Address Fax Number:
732-741-6079
Provider Enumeration Date:
06/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  25MA07439400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9122702 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".