Provider Demographics
NPI:1376993287
Name:CHADDERWALA, VIJAY (DO)
Entity Type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:CHADDERWALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 RXR PLZ FL 13
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-783-4600
Mailing Address - Fax:
Practice Address - Street 1:4724 GREENPOINT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-1710
Practice Address - Country:US
Practice Address - Phone:516-783-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297124207Q00000X
NY274346435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine