Provider Demographics
NPI:1336280692
Name:COMMUNITY GASTROETEROLOGY, PA
Entity Type:Organization
Organization Name:COMMUNITY GASTROETEROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAKRAPANI
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAKASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-505-4420
Mailing Address - Street 1:9 HOSPITAL DR STE 15A
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-6425
Mailing Address - Country:US
Mailing Address - Phone:732-505-4420
Mailing Address - Fax:
Practice Address - Street 1:9 HOSPITAL DR STE 15A
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6425
Practice Address - Country:US
Practice Address - Phone:732-505-4420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA052242207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0349801Medicaid
NJ566818Medicare ID - Type Unspecified
NJE23777Medicare UPIN