Provider Demographics
NPI:1689487035
Name:GOLLARAHALLY-KENCHAP, KUMARASWAMY (PHD)
Entity type:Individual
Prefix:
First Name:KUMARASWAMY
Middle Name:
Last Name:GOLLARAHALLY-KENCHAP
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 BALL ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3521
Mailing Address - Country:US
Mailing Address - Phone:973-877-8357
Mailing Address - Fax:
Practice Address - Street 1:22 BALL ST
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3521
Practice Address - Country:US
Practice Address - Phone:973-877-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPFI9647291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory