Provider Demographics
NPI:1972375996
Name:RAJU THOMAS, TIBU
Entity type:Individual
Prefix:MR
First Name:TIBU
Middle Name:
Last Name:RAJU THOMAS
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 1:109 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:DUMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:07628-2509
Mailing Address - Country:US
Mailing Address - Phone:201-289-3763
Mailing Address - Fax:
Practice Address - Street 1:225 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1523
Practice Address - Country:US
Practice Address - Phone:201-472-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14954700363LA2200X
NY311660363LA2200X
NY675168163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health