Provider Demographics
NPI:1386688968
Name:VANAM, KAMALAKAR (MD)
Entity Type:Individual
Prefix:
First Name:KAMALAKAR
Middle Name:
Last Name:VANAM
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 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:1200 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07061
Practice Address - Country:US
Practice Address - Phone:908-668-2200
Practice Address - Fax:908-668-6894
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67133207P00000X
NJ25MA06713300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0090964Medicaid
NJP00652870OtherRAILROAD MEDICARE
G34439Medicare UPIN
NJ095729XZMMedicare PIN
NJ0090964Medicaid