Provider Demographics
NPI:1487688586
Name:VAIDYA, KETANKUMAR N (MD)
Entity Type:Individual
Prefix:
First Name:KETANKUMAR
Middle Name:N
Last Name:VAIDYA
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 1:2149 WOODBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-4474
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA74514207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9002707Medicaid
NJ063152Medicare PIN
NJH71366Medicare UPIN