Provider Demographics
NPI:1417095845
Name:KETANKUMAR VAIDYA, LLC
Entity Type:Organization
Organization Name:KETANKUMAR VAIDYA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KETANKUMAR
Authorized Official - Middle Name:N
Authorized Official - Last Name:VAIDYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-985-2151
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:SEWAREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07077-0096
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:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA74514207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9002707Medicaid
NJ063152Medicare PIN
NJH71366Medicare UPIN