Provider Demographics
NPI:1316132467
Name:SUSHIL K MEHANDRU MD PA
Entity type:Organization
Organization Name:SUSHIL K MEHANDRU MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD PRESSIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSHIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MEHANDRU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-974-0100
Mailing Address - Street 1:1925 HWY 35
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3512
Mailing Address - Country:US
Mailing Address - Phone:732-974-0100
Mailing Address - Fax:732-974-0137
Practice Address - Street 1:1925 HWY 35
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-3512
Practice Address - Country:US
Practice Address - Phone:732-974-0100
Practice Address - Fax:732-974-0137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA034596305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2634201Medicaid
NJ075963Medicare PIN
NJC52968Medicare UPIN