1740271998 NPI number — RONALD J POBLETE MD

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 1740271998 NPI number — RONALD J POBLETE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POBLETE
Provider First Name:
RONALD
Provider Middle Name:
J
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:
1740271998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
502 HAMBURG TPKE
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
WAYNE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07470-8431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-942-5224
Provider Business Mailing Address Fax Number:
973-942-7443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
289 MARKET ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SADDLE BROOK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07663-6048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-587-9204
Provider Business Practice Location Address Fax Number:
201-587-0623
Provider Enumeration Date:
11/04/2005

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: 207R00000X , with the licence number:  25MA05479500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 25MA05479500 , 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: 4645405 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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