1487665717 NPI number — JAROSLAW S PONDO MD

Table of content: JAROSLAW S PONDO MD (NPI 1487665717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487665717 NPI number — JAROSLAW S PONDO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PONDO
Provider First Name:
JAROSLAW
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1487665717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 UNION AVE
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
RUTHERFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07070-1274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-896-0050
Provider Business Mailing Address Fax Number:
201-896-0051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
71 UNION AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
RUTHERFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07070-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-896-0050
Provider Business Practice Location Address Fax Number:
201-896-0051
Provider Enumeration Date:
08/11/2006

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: 207RP1001X , with the licence number:  25MA07479000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 25MA07479000 , 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: 0185540 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com