1073687356 NPI number — DR. SUSAN PAKRAVAN COCOZIELLO M.D.

Table of content: DR. SUSAN PAKRAVAN COCOZIELLO M.D. (NPI 1073687356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073687356 NPI number — DR. SUSAN PAKRAVAN COCOZIELLO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COCOZIELLO
Provider First Name:
SUSAN
Provider Middle Name:
PAKRAVAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1073687356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BROADWAY
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
ELMWOOD PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07407-1843
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
201-794-7717
Provider Business Mailing Address Fax Number:
201-794-7717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
ELMWOOD PARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07407-1842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-773-6777
Provider Business Practice Location Address Fax Number:
201-300-6880
Provider Enumeration Date:
11/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1915908 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".