Provider Demographics
NPI:1235135880
Name:PUVABANDITSIN, SURASAK (MD)
Entity Type:Individual
Prefix:DR
First Name:SURASAK
Middle Name:
Last Name:PUVABANDITSIN
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 1:32 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-5968
Mailing Address - Country:US
Mailing Address - Phone:732-980-9308
Mailing Address - Fax:732-980-0033
Practice Address - Street 1:1 ROBERT WOOD JOHNSON PL
Practice Address - Street 2:MEB 396
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1928
Practice Address - Country:US
Practice Address - Phone:732-235-5691
Practice Address - Fax:732-235-5668
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA041601002080N0001X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3816508Medicaid
NJ3816508Medicaid
688572CY4Medicare PIN