1063562445 NPI number — DR. DAVID MICHAEL DERAMO M.D.

Table of content: DR. DAVID MICHAEL DERAMO M.D. (NPI 1063562445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063562445 NPI number — DR. DAVID MICHAEL DERAMO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERAMO
Provider First Name:
DAVID
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1063562445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 GRAND AVE
Provider Second Line Business Mailing Address:
ENGLEWOOD KNEE & SPORTS MEDICINE,SUITE 100
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07631-4154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-567-5700
Provider Business Mailing Address Fax Number:
201-567-8049

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 GRAND AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07631-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
15-675-7002
Provider Business Practice Location Address Fax Number:
201-567-8049
Provider Enumeration Date:
01/10/2007

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: 207XX0005X , with the licence number:  25MA08226000 , 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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