Provider Demographics
NPI:1952744872
Name:PUDCHONG SRISETHNIL, MD, PA
Entity Type:Organization
Organization Name:PUDCHONG SRISETHNIL, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PUDCHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:SRISETHNIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-278-4673
Mailing Address - Street 1:561 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-1862
Mailing Address - Country:US
Mailing Address - Phone:973-278-4673
Mailing Address - Fax:973-278-0450
Practice Address - Street 1:561 E 28TH ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-1862
Practice Address - Country:US
Practice Address - Phone:973-278-4673
Practice Address - Fax:973-278-0450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RE0101X
NJMA30779207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC53578Medicare UPIN
NJSR150152Medicare PIN