1265692073 NPI number — DR. JOHNY DENIS ARDELJAN DO

Table of content: KIMBERLY A MUFFIE PA-C (NPI 1720182306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265692073 NPI number — DR. JOHNY DENIS ARDELJAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ARDELJAN
Provider First Name:
JOHNY
Provider Middle Name:
DENIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1265692073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 GREAT NECK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT NECK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11021-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-487-4464
Provider Business Mailing Address Fax Number:
516-487-4950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1202 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28401-7307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-341-3300
Provider Business Practice Location Address Fax Number:
910-251-2067
Provider Enumeration Date:
06/16/2008

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: 2084N0400X , with the licence number:  2538571 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 2018-00949 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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