Provider Demographics
NPI:1124055272
Name:KAMBAM, SHRAVAN REDDY (MD)
Entity type:Individual
Prefix:
First Name:SHRAVAN
Middle Name:REDDY
Last Name:KAMBAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 BROAD STREET
Mailing Address - Street 2:SUITE B-130
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3085
Mailing Address - Country:US
Mailing Address - Phone:973-873-7000
Mailing Address - Fax:973-873-7035
Practice Address - Street 1:160 PEHLE AVENUE
Practice Address - Street 2:
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-5227
Practice Address - Country:US
Practice Address - Phone:201-881-1000
Practice Address - Fax:201-226-0401
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07943002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I50783Medicare UPIN
NJ099530Medicare ID - Type Unspecified