Healthcare Provider Details

I. General information

NPI: 1043890775
Provider Name (Legal Business Name): VIDYA MANI MEDEPALLI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 702
HACKENSACK NJ
07601-1974
US

IV. Provider business mailing address

20 PROSPECT AVE STE 702
HACKENSACK NJ
07601-1974
US

V. Phone/Fax

Practice location:
  • Phone: 908-359-8980
  • Fax:
Mailing address:
  • Phone: 908-359-8980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number25MA12744700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA12744700
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: