Provider Demographics
NPI:1518064260
Name:KOMMIREDDI, SOWMINI
Entity Type:Individual
Prefix:DR
First Name:SOWMINI
Middle Name:
Last Name:KOMMIREDDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 STATE ROUTE 34
Mailing Address - Street 2:SUITE V
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-3469
Mailing Address - Country:US
Mailing Address - Phone:732-290-1063
Mailing Address - Fax:732-290-1384
Practice Address - Street 1:1070 STATE ROUTE 34
Practice Address - Street 2:SUITE V
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-3469
Practice Address - Country:US
Practice Address - Phone:732-290-1063
Practice Address - Fax:732-290-1384
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA073809305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9072802Medicaid