Provider Demographics
NPI:1255340345
Name:VADAKARA, LUKOSE SIMON (MD)
Entity type:Individual
Prefix:DR
First Name:LUKOSE
Middle Name:SIMON
Last Name:VADAKARA
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 1:21 WILLETTA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4862
Mailing Address - Country:US
Mailing Address - Phone:732-961-6225
Mailing Address - Fax:
Practice Address - Street 1:1401 WHITEHORSE MERCERVILLE RD STE 220
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3835
Practice Address - Country:US
Practice Address - Phone:609-249-6664
Practice Address - Fax:609-249-6665
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69469207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ60025158OtherHORIZON NJ HEALTH
NJ8013004Medicaid
NJ60025158OtherHORIZON NJ HEALTH
NJH01830Medicare UPIN