Healthcare Provider Details

I. General information

NPI: 1750470209
Provider Name (Legal Business Name): INDU MADHOK M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 ROSEVILLE AVE
NEWARK NJ
07107-1619
US

IV. Provider business mailing address

156 ROSEVILLE AVE
NEWARK NJ
07107-1619
US

V. Phone/Fax

Practice location:
  • Phone: 973-484-3848
  • Fax: 973-484-5226
Mailing address:
  • Phone: 973-484-3848
  • Fax: 973-484-5226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA39591
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3847101
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: