Provider Demographics
NPI:1225486905
Name:SUTHARSANAM, BALAJI (MD)
Entity Type:Individual
Prefix:DR
First Name:BALAJI
Middle Name:
Last Name:SUTHARSANAM
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 1:60 VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824-1546
Mailing Address - Country:US
Mailing Address - Phone:908-616-3097
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:551-996-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJS94800710005902390200000X
NJ25MA106313002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program