Provider Demographics
NPI:1477919710
Name:VANITHA YADALLA MD LLC
Entity Type:Organization
Organization Name:VANITHA YADALLA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YADALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-521-4636
Mailing Address - Street 1:3350 RTE 138
Mailing Address - Street 2:SUITE 128, BLDG 2
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9693
Mailing Address - Country:US
Mailing Address - Phone:732-280-2727
Mailing Address - Fax:732-280-1147
Practice Address - Street 1:3350 RTE 138
Practice Address - Street 2:SUITE 128, BLDG 2
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9693
Practice Address - Country:US
Practice Address - Phone:732-280-2727
Practice Address - Fax:732-280-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07674100261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI04810Medicare UPIN