Healthcare Provider Details

I. General information

NPI: 1538110754
Provider Name (Legal Business Name): VIJU VIJAYSADAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 KINNELON RD SUITE 28
KINNELON NJ
07405-2347
US

IV. Provider business mailing address

170 KINNELON RD SUITE 28
KINNELON NJ
07405-2347
US

V. Phone/Fax

Practice location:
  • Phone: 973-838-7650
  • Fax: 973-838-1775
Mailing address:
  • Phone: 973-838-7650
  • Fax: 973-838-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08006300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA08006300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: