Provider Demographics
NPI:1669470308
Name:JONNALAGADDA, VASUDEVARAO (MD)
Entity type:Individual
Prefix:
First Name:VASUDEVARAO
Middle Name:
Last Name:JONNALAGADDA
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 1:3438 JOHN F KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-4166
Mailing Address - Country:US
Mailing Address - Phone:201-420-0366
Mailing Address - Fax:201-420-6422
Practice Address - Street 1:3438 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-4166
Practice Address - Country:US
Practice Address - Phone:201-420-0366
Practice Address - Fax:201-420-6422
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06324000207RN0300X
NY199878-1207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01918538Medicaid
NJP00094722OtherRAILROAD MEDICARE
NJ7378106Medicaid
NJ0036536Medicaid
NJ043714808OtherHORIZON B/C B/S
NJDB2462OtherRAILROAD MEDICARE GROUP #
NY01918538Medicaid
NJ043714808OtherHORIZON B/C B/S
NJ077061Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER