Healthcare Provider Details

I. General information

NPI: 1457092306
Provider Name (Legal Business Name): PRASANNA TATI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

IV. Provider business mailing address

408 4TH AVE
HADDON HEIGHTS NJ
08035-1311
US

V. Phone/Fax

Practice location:
  • Phone: 732-923-6795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MB13305300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: