Healthcare Provider Details

I. General information

NPI: 1780039404
Provider Name (Legal Business Name): PALLAVI DODDAKASHI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 602
HACKENSACK NJ
07601-1962
US

IV. Provider business mailing address

3600 STATE ROUTE 66 FL 3
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2442
  • Fax: 201-343-1045
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD047337
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number0101269635
License Number StateVA

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: