Basic Information
Provider Information | |||||||||
NPI: | 1679589121 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUSTGI | ||||||||
FirstName: | VINOD | ||||||||
MiddleName: | KUMAR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 66 W GILBERT ST FL 2 | ||||||||
Address2: |   | ||||||||
City: | TINTON FALLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 077014947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2017596921 | ||||||||
FaxNumber: | 7322120713 | ||||||||
Practice Location | |||||||||
Address1: | 125 PATERSON ST STE 5100 | ||||||||
Address2: |   | ||||||||
City: | NEW BRUNSWICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 089011962 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322357784 | ||||||||
FaxNumber: | 7322357792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 07/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD-029154E | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 25MA09823400 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 223602 | 01 | VA | ANTHEM | OTHER | 43780001 | 01 | DC | BCBS | OTHER | 100012180 | 01 |   | RAILROAD MEDICARE | OTHER |