Provider Demographics
NPI:1194047068
Name:THALAYUR, KEERTI (MD)
Entity type:Individual
Prefix:
First Name:KEERTI
Middle Name:
Last Name:THALAYUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT ROYAL
Mailing Address - State:NJ
Mailing Address - Zip Code:08061-1097
Mailing Address - Country:US
Mailing Address - Phone:201-233-0896
Mailing Address - Fax:
Practice Address - Street 1:646 KINGS HWY
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-879-2887
Practice Address - Fax:856-879-2855
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA08950300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program