Basic Information
| Provider Information | |||||||||
| NPI: | 1710128046 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THAKALLAPALI | ||||||||
| FirstName: | SANDHYA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 53 S LAUREL ST | ||||||||
| Address2: | FLOOR 2 | ||||||||
| City: | BRIDGETON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083021946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564514700 | ||||||||
| FaxNumber: | 8564518685 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 W LANDIS AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083608101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564514700 | ||||||||
| FaxNumber: | 8564518685 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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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 | 207Q00000X | 25MA08538300 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NJ | MEDICAID |