1831748045 NPI number — DR. ADAM FAN DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831748045 NPI number — DR. ADAM FAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAN
Provider First Name:
ADAM
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

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:
1831748045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/11/2022
NPI Reactivation Date:
08/04/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 JEFFERSON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOTSWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08884-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-598-4647
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 BOUND BROOK RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLESEX
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08846-2155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-968-4422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2019

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: 225100000X , with the licence number:  40QA01876500 , 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)