Provider Demographics
NPI:1780629899
Name:SUNDERRAM, JAG (MD)
Entity Type:Individual
Prefix:
First Name:JAG
Middle Name:
Last Name:SUNDERRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:125 PATERSON ST
Practice Address - Street 2:SUITE 5200B
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-6511
Practice Address - Fax:732-235-6524
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA063185207RP1001X
NJ25MA06318500207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ290012185OtherR R MCR
NJ8025908Medicaid
NJ8025908Medicaid
NJ290012185OtherR R MCR
NJH03131Medicare UPIN