Provider Demographics
NPI:1326186768
Name:TARA P. KANETKAR, MD, PA
Entity Type:Organization
Organization Name:TARA P. KANETKAR, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KANETKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-985-2151
Mailing Address - Street 1:2149 WOODBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-4474
Mailing Address - Country:US
Mailing Address - Phone:732-985-2151
Mailing Address - Fax:732-985-0650
Practice Address - Street 1:2149 WOODBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-4474
Practice Address - Country:US
Practice Address - Phone:732-985-2151
Practice Address - Fax:732-985-0650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA023527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2091704Medicaid
NJ2091704Medicaid
NJC55813Medicare UPIN