Basic Information
| Provider Information | |||||||||
| NPI: | 1649466277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOONTHUNGAL | ||||||||
| FirstName: | SUNITHA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN ST RM 1205 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 230 E RIDGEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019674000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 253701 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 25MA08591300 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0217361 | 05 | NJ | MEDICAID |