Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0204X | Pediatric Emergency Doctor | 25MA06802600 | NJ |
NPI | 1114958451 |
---|---|
Provider Name | Noah Praveen Kumar Kondamudi |
First Address | Newark, NJ 07107-3000 |
Second Address | Newark, NJ 07107-3000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8778205 | (05) | NJ |
G43523 | (02) |