1720003676 NPI number — SUSHILA VARADARAJAN M.D.

Table of content: SUSHILA VARADARAJAN M.D. (NPI 1720003676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720003676 NPI number — SUSHILA VARADARAJAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARADARAJAN
Provider First Name:
SUSHILA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1720003676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 754
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILLVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08332-0754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-690-1025
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 W SHERMAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINELAND
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08360-6912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-641-8000
Provider Business Practice Location Address Fax Number:
856-641-7623
Provider Enumeration Date:
07/13/2006

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: 174400000X , with the licence number:  25 MA03141300 , 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: 5203601 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".