Healthcare Provider Details

I. General information

NPI: 1386688968
Provider Name (Legal Business Name): KAMALAKAR VANAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PARK AVE
PLAINFIELD NJ
07061
US

IV. Provider business mailing address

307 S EVERGREEN AVE
WOODBURY NJ
08096-2739
US

V. Phone/Fax

Practice location:
  • Phone: 908-668-2200
  • Fax: 908-668-6894
Mailing address:
  • Phone: 856-686-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMA67133
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06713300
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier0090964
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
IdentifierP00652870
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: