Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207Q00000X | Family Medicine | | 25MA04727700 | NEW JERSEY | No |
| 2 | 2085R0202X | Radiology | Diagnostic Radiology | 25MA04727700 | NEW JERSEY | No |
| 3 | 208600000X | Surgery | | 25MA04727700 | NEW JERSEY | No |
| 4 | 207R00000X | Internal Medicine | | 25MA04727700 | NEW JERSEY | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 0396670001 | OTHER | NEW JERSEY | AMERIHEALTH ADMINISTRATOR |
| 2 | 80340 | OTHER | NEW JERSEY | AMERIGROUP |
| 3 | ========= | OTHER | NEW JERSEY | LOCAL 54 |
| 4 | ========= | OTHER | NEW JERSEY | UNITED HEALTHCARE |
| 5 | OK6443 | OTHER | NEW JERSEY | HEALTHNET |
| 6 | 0010972 | OTHER | NEW JERSEY | US HEALTHCARE |
| 7 | 0396670001 | OTHER | NEW JERSEY | AMERIHEALTH |
| 8 | 575019 | OTHER | PENNSYLVANIA | PENNSYLVANIA BLUE SHIELD |
| 9 | ========= | OTHER | NEW JERSEY | AETNA |
| 10 | ========= | OTHER | NEW JERSEY | CIGNA |
| 11 | 575019 | MEDICARE ID-TYPE UNSPECIFIED | NEW JERSEY | MEDICARE NJ |
| 12 | ========= | OTHER | NEW JERSEY | TRICARE / CHAMPUS |
| 13 | ATP016 | OTHER | NEW JERSEY | OXFORD |
| 14 | 2========= | OTHER | NEW JERSEY | HORIZON BLUE SHIELD |
| 15 | C58176 | MEDICARE UPIN | NEW JERSEY | |
| 16 | 3594700 | MEDICAID | NEW JERSEY | |
