Healthcare Provider Details

I. General information

NPI: 1326468307
Provider Name (Legal Business Name): SUNIL KUKREJA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 08/21/2021
Certification Date: 08/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 WOODHAVEN BLVD
REGO PARK NY
11374-5048
US

IV. Provider business mailing address

105 FOURTH ST
EDISON NJ
08837-2653
US

V. Phone/Fax

Practice location:
  • Phone: 718-255-6615
  • Fax:
Mailing address:
  • Phone: 318-655-4393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA10361300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number292135
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number25MA10361300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number292135
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: