Provider Demographics
NPI:1962031450
Name:VRIDHACHALAM, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:VRIDHACHALAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3286 41ST ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3501
Mailing Address - Country:US
Mailing Address - Phone:646-755-0035
Mailing Address - Fax:
Practice Address - Street 1:333 15TH ST FL 2R
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3429
Practice Address - Country:US
Practice Address - Phone:201-482-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11800700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics