Healthcare Provider Details

I. General information

NPI: 1235135880
Provider Name (Legal Business Name): SURASAK PUVABANDITSIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROBERT WOOD JOHNSON PL MEB 396
NEW BRUNSWICK NJ
08901-1928
US

IV. Provider business mailing address

32 CARRIAGE DR
PISCATAWAY NJ
08854-5968
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-5691
  • Fax: 732-235-5668
Mailing address:
  • Phone: 732-980-9308
  • Fax: 732-980-0033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA04160100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA04160100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: