Provider Demographics
NPI:1063927812
Name:VARGHESE, PRADOSH
Entity type:Individual
Prefix:MR
First Name:PRADOSH
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 TWINBORO LN
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-1245
Mailing Address - Country:US
Mailing Address - Phone:551-497-8255
Mailing Address - Fax:
Practice Address - Street 1:124 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3502
Practice Address - Country:US
Practice Address - Phone:973-695-0885
Practice Address - Fax:973-771-3575
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00459800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant