Healthcare Provider Details

I. General information

NPI: 1568641058
Provider Name (Legal Business Name): SANDARSH RAJ KANCHERLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 GRAND AVE
ENGLEWOOD NJ
07631-4152
US

IV. Provider business mailing address

420 GRAND AVE
ENGLEWOOD NJ
07631-4152
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-7044
  • Fax: 201-569-1999
Mailing address:
  • Phone: 201-569-7044
  • Fax: 201-569-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT188777
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number252443
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA09096400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: