1740403435 NPI number — WILLIAM J DERKASCH CYRUS G DEHKAN PTRS

Table of content: MS. THAIS GOESE SOUSA CNP (NPI 1356061345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740403435 NPI number — WILLIAM J DERKASCH CYRUS G DEHKAN PTRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLIAM J DERKASCH CYRUS G DEHKAN PTRS
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:
6
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:
1740403435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
409 BOULEVARD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENILWORTH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07033-1538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-276-2225
Provider Business Mailing Address Fax Number:
908-276-1550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
409 BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENILWORTH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07033-1538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-276-2225
Provider Business Practice Location Address Fax Number:
908-276-1550
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DERKASCH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
GENERAL PARTNER
Authorized Official Telephone Number:
908-276-2225

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  22DI01560000 , 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)





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