1295192706 NPI number — DERRICK M DESILVA JR. M.D. LLC

Table of content: (NPI 1295192706)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295192706 NPI number — DERRICK M DESILVA JR. M.D. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERRICK M DESILVA JR. M.D. LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295192706
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
629 AMBOY AVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
EDISON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08837-3579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-738-8801
Provider Business Mailing Address Fax Number:
732-738-8802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 AMBOY AVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
EDISON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08837-3579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-738-8801
Provider Business Practice Location Address Fax Number:
732-738-8802
Provider Enumeration Date:
01/28/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DESILVA
Authorized Official First Name:
DERRICK
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
732-738-8801

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  25MA05140000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com