MEDICARE: DR. PUDCHONG S SRISETHNIL M.D., F.A.C.E.

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	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	MA30779	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA30779	OTHER	NJ	LICENSE #
2	222385269	OTHER	NJ	TAX ID

General Provider Information

NPI Number	:	1770690315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PUDCHONG S SRISETHNIL M.D., F.A.C.E.

Provider Business Mailing Address
First Line	:	561 E 28TH ST
Second Line	:
City	:	PATERSON
State	:	NJ
Zip	:	07504-1825
Country	:	US
Telephone Number	:	973-278-4673
Fax Number	:	973-278-0450

Provider Business Practice Location Address
First Line	:	561 E 28TH ST
Second Line	:
City	:	PATERSON
State	:	NJ
Zip	:	07504-1825
Country	:	US
Telephone Number	:	973-278-4673
Fax Number	:	973-278-0450

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	03/07/2023

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