Provider Demographics
NPI:1033101035
Name:ZIYAAUDHIN, KAPPUKALAR A (MD)
Entity Type:Individual
Prefix:
First Name:KAPPUKALAR
Middle Name:A
Last Name:ZIYAAUDHIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 W MARKET ST
Mailing Address - Street 2:STE 211A
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2783
Mailing Address - Country:US
Mailing Address - Phone:973-623-9011
Mailing Address - Fax:973-624-1208
Practice Address - Street 1:186 W MARKET ST
Practice Address - Street 2:STE 211A
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2783
Practice Address - Country:US
Practice Address - Phone:973-623-9011
Practice Address - Fax:973-624-1208
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03218600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3035506Medicaid
NJ3035506Medicaid
540767Medicare ID - Type Unspecified