Healthcare Provider Details

I. General information

NPI: 1225965247
Provider Name (Legal Business Name): MR. PAVAN SUKUMAR KODGI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 POCONO ROAD
DENVILLE NJ
07834
US

IV. Provider business mailing address

THE NEW YORK MEDICAL COLLEGE GRADUATE MEDICAL EDUCATION 25 POCONO ROAD, GME OFFICE 2ND FLOOR, C-WING
DENVILLE NJ
07834
US

V. Phone/Fax

Practice location:
  • Phone: 973-983-5583
  • Fax:
Mailing address:
  • Phone: 973-983-5583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: