Healthcare Provider Details

I. General information

NPI: 1659302578
Provider Name (Legal Business Name): NUTAN SHIRISH NADKARNI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PRATIMA VASANT KANTAK MBBS

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3826 PARK AVE SUITE 101
EDISON NJ
08820-2508
US

IV. Provider business mailing address

3826 PARK AVE SUITE 101
EDISON NJ
08820-2508
US

V. Phone/Fax

Practice location:
  • Phone: 732-744-9400
  • Fax: 732-516-0608
Mailing address:
  • Phone: 732-744-9400
  • Fax: 732-516-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA06880000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11590963
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerCAQH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: