Healthcare Provider Details

I. General information

NPI: 1699784637
Provider Name (Legal Business Name): LODI INTERNIST GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 GARIBALDI AVE
LODI NJ
07644-3709
US

IV. Provider business mailing address

361 GARIBALDI AVE
LODI NJ
07644-3709
US

V. Phone/Fax

Practice location:
  • Phone: 973-773-3556
  • Fax:
Mailing address:
  • Phone: 973-773-3556
  • Fax: 973-773-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: VIJAY THAMMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 973-773-3556