Provider Demographics
NPI:1093702961
Name:YADALLA, VANITHA (MD)
Entity Type:Individual
Prefix:
First Name:VANITHA
Middle Name:
Last Name:YADALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VANITHA
Other - Middle Name:
Other - Last Name:SEENIVASAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3350 RTE 138 STE 128
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9694
Mailing Address - Country:US
Mailing Address - Phone:732-280-2727
Mailing Address - Fax:
Practice Address - Street 1:3350 RTE 138 WEST
Practice Address - Street 2:SUITE 128, BLDG 2
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-4404
Practice Address - Country:US
Practice Address - Phone:732-280-2727
Practice Address - Fax:732-280-1147
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07674100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0054941Medicaid
I04810Medicare UPIN
NJ0054941Medicaid