Provider Demographics
NPI:1205240025
Name:ESSEX PRIMARY CARE PC
Entity type:Organization
Organization Name:ESSEX PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMATHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GADARLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-726-4358
Mailing Address - Street 1:825 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1366
Mailing Address - Country:US
Mailing Address - Phone:973-794-1185
Mailing Address - Fax:973-669-5988
Practice Address - Street 1:526 BLOOMFIELD AVE STE 103
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5525
Practice Address - Country:US
Practice Address - Phone:973-239-1600
Practice Address - Fax:973-559-6188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08121700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ11984WH9Medicare UPIN