Provider Demographics
NPI:1770545501
Name:KODIYALAM, UTHRA (MD,)
Entity type:Individual
Prefix:
First Name:UTHRA
Middle Name:
Last Name:KODIYALAM
Suffix:
Gender:F
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 PRINCETON DR
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1219
Mailing Address - Country:US
Mailing Address - Phone:908-286-0265
Mailing Address - Fax:
Practice Address - Street 1:55 MORRIS AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1426
Practice Address - Country:US
Practice Address - Phone:973-379-9601
Practice Address - Fax:973-467-6779
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA066933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMA066933OtherLICENSE
NJG88046Medicare UPIN