Healthcare Provider Details

I. General information

NPI: 1366453409
Provider Name (Legal Business Name): SUSHIL K MEHANDRU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 HWY 35 W
WALL NJ
07719
US

IV. Provider business mailing address

1925 HWY 35
WALL NJ
07719
US

V. Phone/Fax

Practice location:
  • Phone: 732-974-0100
  • Fax: 732-974-0137
Mailing address:
  • Phone: 732-974-0100
  • Fax: 732-974-0137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMA034596
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: