Provider Demographics
NPI:1710128046
Name:THAKALLAPALI, SANDHYA (MD)
Entity Type:Individual
Prefix:
First Name:SANDHYA
Middle Name:
Last Name:THAKALLAPALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 S LAUREL ST
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-1946
Mailing Address - Country:US
Mailing Address - Phone:856-451-4700
Mailing Address - Fax:856-451-8685
Practice Address - Street 1:319 W LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-8101
Practice Address - Country:US
Practice Address - Phone:856-451-4700
Practice Address - Fax:856-451-8685
Is Sole Proprietor?:No
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08538300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPENDINGMedicaid
NJPENDINGMedicaid