MEDICARE: KETANKUMAR VAIDYA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	MA74514	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417095845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KETANKUMAR VAIDYA, LLC

Provider Business Mailing Address
First Line	:	PO BOX 96
Second Line	:
City	:	SEWAREN
State	:	NJ
Zip	:	07077-0096
Country	:	US
Telephone Number	:	732-985-2151
Fax Number	:	732-985-0650

Provider Business Practice Location Address
First Line	:	2149 WOODBRIDGE AVE
Second Line	:
City	:	EDISON
State	:	NJ
Zip	:	08817-4474
Country	:	US
Telephone Number	:	732-985-2151
Fax Number	:	732-985-0650

Authorized Official
Title or Position	:	OWNER
Name	:	KETANKUMAR N VAIDYA
Credential	:	MD
Telephone Number	:	732-985-2151

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	06/11/2012

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