Healthcare Provider Details

I. General information

NPI: 1285977256
Provider Name (Legal Business Name): PAUL JAI THERATTIL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W ESSEX ST STE 202
MAYWOOD NJ
07607-1023
US

IV. Provider business mailing address

211 WOODBINE CIR
NEW PROVIDENCE NJ
07974-1737
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-8092
  • Fax: 201-603-1993
Mailing address:
  • Phone:
  • Fax: 201-603-1993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number25MA10358100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: