Healthcare Provider Details

I. General information

NPI: 1699424101
Provider Name (Legal Business Name): AVANI MANASA KOLLA PATEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 8TH ST
SECAUCUS NJ
07094-3019
US

IV. Provider business mailing address

737 8TH ST
SECAUCUS NJ
07094-3019
US

V. Phone/Fax

Practice location:
  • Phone: 952-992-9220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA12976500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: