Healthcare Provider Details

I. General information

NPI: 1063152197
Provider Name (Legal Business Name): JONATHAN RAMESH VAMADEVA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 VALLEY RD STE 201
WAYNE NJ
07470-3534
US

IV. Provider business mailing address

504 VALLEY RD STE 201
WAYNE NJ
07470-3534
US

V. Phone/Fax

Practice location:
  • Phone: 973-446-7500
  • Fax: 973-554-4922
Mailing address:
  • Phone: 973-446-7500
  • Fax: 973-554-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number25MB12720800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: