1154407500 NPI number — DR. MICHAEL ERNEST FUSARO DPM

Table of content: DR. MICHAEL ERNEST FUSARO DPM (NPI 1154407500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154407500 NPI number — DR. MICHAEL ERNEST FUSARO DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUSARO
Provider First Name:
MICHAEL
Provider Middle Name:
ERNEST
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1154407500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 WOODLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VERONA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07044-2813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-857-9656
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32 HINE ST
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
PATERSON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07503-2955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-742-9111
Provider Business Practice Location Address Fax Number:
973-742-9017
Provider Enumeration Date:
10/28/2006

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: 213EP1101X , with the licence number:  MD02486 , 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)

  • Identifier: P1988634 . This is a "OXFORD PIN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1110186 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7773102 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1K6547 . This is a "HELATHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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