Healthcare Provider Details

I. General information

NPI: 1790533081
Provider Name (Legal Business Name): UJWAL SAI BOPPANA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 01/27/2025
Certification Date:
Deactivation Date: 01/10/2025
Reactivation Date: 01/27/2025

III. Provider practice location address

30 PROSPECT AVE EMERGENCY DEPARTMENT
HACKENSACK NJ
07601
US

IV. Provider business mailing address

30 PROSPECT AVENUE 3620 MAIN BUILDING
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2000
  • Fax:
Mailing address:
  • Phone: 551-996-2000
  • Fax: 551-996-0937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

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: