Provider Demographics
NPI:1407153265
Name:PUTCHA, NITIN (DO)
Entity Type:Individual
Prefix:DR
First Name:NITIN
Middle Name:
Last Name:PUTCHA
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 1:103 RIVER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1016
Mailing Address - Country:US
Mailing Address - Phone:201-308-8995
Mailing Address - Fax:201-917-3603
Practice Address - Street 1:103 RIVER RD
Practice Address - Street 2:STE 101
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1016
Practice Address - Country:US
Practice Address - Phone:201-308-8995
Practice Address - Fax:201-917-3603
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53503208100000X, 208100000X
NJ09614400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057927Medicaid
CTP01493626OtherRR MEDICARE
CT008057927Medicaid
NJ411723Medicare PIN