Provider Demographics
NPI:1033817879
Name:GANGISETTY, SUSHMA (OD)
Entity Type:Individual
Prefix:
First Name:SUSHMA
Middle Name:
Last Name:GANGISETTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 CABOT WAY
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08823-1766
Mailing Address - Country:US
Mailing Address - Phone:979-220-8689
Mailing Address - Fax:
Practice Address - Street 1:300 HIGHWAY 35 STE 300
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2216
Practice Address - Country:US
Practice Address - Phone:732-222-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00716400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty