Provider Demographics
NPI:1295797256
Name:LALLA, SANJAY (M D)
Entity type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:LALLA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 NORTHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3024
Mailing Address - Country:US
Mailing Address - Phone:973-324-9455
Mailing Address - Fax:973-324-9454
Practice Address - Street 1:383 NORTHFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3024
Practice Address - Country:US
Practice Address - Phone:973-324-9455
Practice Address - Fax:973-324-9454
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA58573208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7222904Medicaid
G46776Medicare UPIN
NJ767490Medicare PIN