Healthcare Provider Details

I. General information

NPI: 1669882452
Provider Name (Legal Business Name): KHALID SADRUL ANAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314-316 ORANGE ROAD
MONTCLAIR NJ
07042
US

IV. Provider business mailing address

314-316 ORANGE ROAD TRIBECA PEDIATRICS
MONTCLAIR NJ
07042
US

V. Phone/Fax

Practice location:
  • Phone: 862-213-0769
  • Fax:
Mailing address:
  • Phone: 862-213-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA10155000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: