Provider Demographics
NPI:1457628703
Name:DANDU, VIJAY R (MS)
Entity Type:Individual
Prefix:MR
First Name:VIJAY
Middle Name:R
Last Name:DANDU
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-2500
Mailing Address - Country:US
Mailing Address - Phone:201-432-6968
Mailing Address - Fax:201-432-7004
Practice Address - Street 1:119 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-2500
Practice Address - Country:US
Practice Address - Phone:201-432-6968
Practice Address - Fax:201-432-7004
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2017-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI022076001835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9092501Medicaid