Provider Demographics
NPI:1760618383
Name:HOLMDEL PEDIATRICS, LLC
Entity Type:Organization
Organization Name:HOLMDEL PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SOWMINI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMMIREDDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-290-1063
Mailing Address - Street 1:719 N BEERS ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1522
Mailing Address - Country:US
Mailing Address - Phone:732-290-1063
Mailing Address - Fax:732-739-9537
Practice Address - Street 1:719 N BEERS ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1522
Practice Address - Country:US
Practice Address - Phone:732-290-1063
Practice Address - Fax:732-739-9537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0738092080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1154462604OtherNPI
NJ9078502Medicaid
NJ1518064260OtherNPI