Healthcare Provider Details

I. General information

NPI: 1730576919
Provider Name (Legal Business Name): DR. SANDOLSAM CHA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 ELIZABETH AVE
ELIZABETH NJ
07201-2200
US

IV. Provider business mailing address

305 E 161ST ST
BRONX NY
10451-3535
US

V. Phone/Fax

Practice location:
  • Phone: 908-351-5384
  • Fax:
Mailing address:
  • Phone: 718-579-2568
  • Fax: 718-410-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD483547
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number295891
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA11436700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: