Provider Demographics
NPI:1639381858
Name:GHANSHYAM LALLA & PUSHPA LALLA PC
Entity Type:Organization
Organization Name:GHANSHYAM LALLA & PUSHPA LALLA PC
Other - Org Name:GHANSHYAM LALLA & PUSHPA LALLA PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GHANSHYAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:LALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-736-7750
Mailing Address - Street 1:383 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3024
Mailing Address - Country:US
Mailing Address - Phone:973-736-7750
Mailing Address - Fax:973-669-9691
Practice Address - Street 1:383 NORTHFIELD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3024
Practice Address - Country:US
Practice Address - Phone:973-736-7750
Practice Address - Fax:973-669-9691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26258207Q00000X
NJ25819207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Single Specialty