Provider Demographics
NPI:1770690315
Name:SRISETHNIL, PUDCHONG S (MD, FACE)
Entity Type:Individual
Prefix:DR
First Name:PUDCHONG
Middle Name:S
Last Name:SRISETHNIL
Suffix:
Gender:M
Credentials:MD, FACE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-1825
Mailing Address - Country:US
Mailing Address - Phone:973-278-4673
Mailing Address - Fax:973-278-0450
Practice Address - Street 1:561 E 28TH ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-1825
Practice Address - Country:US
Practice Address - Phone:973-278-4673
Practice Address - Fax:973-278-0450
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA30779207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA30779OtherLICENSE #
NJ222385269OtherTAX ID
NJ222385269OtherTAX ID
NJC53578Medicare UPIN
NJMA30779OtherLICENSE #