Provider Demographics
NPI:1225172638
Name:MUNDASSERY, SARALA C (MD)
Entity Type:Individual
Prefix:
First Name:SARALA
Middle Name:C
Last Name:MUNDASSERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 WOODMONT DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2119
Mailing Address - Country:US
Mailing Address - Phone:609-882-3999
Mailing Address - Fax:609-921-9411
Practice Address - Street 1:69 WOODMONT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2119
Practice Address - Country:US
Practice Address - Phone:609-882-3999
Practice Address - Fax:609-921-9411
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA24687002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0930806Medicaid
NJ448779Medicare ID - Type Unspecified
NJ0930806Medicaid