Healthcare Provider Details

I. General information

NPI: 1184783490
Provider Name (Legal Business Name): VASUDHA CHUNDRU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 SPRINGFIELD AVE
WESTFIELD NJ
07090-1001
US

IV. Provider business mailing address

66 W GILBERT ST 2ND FLOOR
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 908-518-3743
  • Fax: 908-228-3621
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06628300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: