Healthcare Provider Details

I. General information

NPI: 1982019774
Provider Name (Legal Business Name): TAARAN CARIAPPA BALLACHANDA SUBBAIAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVENUE JOHNSON HALL (DEPT. OF INTERNAL MEDICINE)
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVENUE JOHNSON HALL (DEPT. OF INTERNAL MEDICINE)
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-1330
  • Fax: 551-996-3298
Mailing address:
  • Phone: 551-996-1330
  • Fax: 551-996-3298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA10622400
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier25MA10622400
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNJ DIVISION OF CONSUMER AFFAIRS, BOARD OF MEDICAL EXAMINERS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: