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 | 174400000X | Specialist | | 1940031 | NEW YORK | No |
| 2 | 174400000X | Specialist | | 25MA06229000 | 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 | 5601313 | OTHER | NEW JERSEY | AETNA TRADITIONAL PLAN |
| 2 | P611714 | OTHER | NEW JERSEY | OXFORD |
| 3 | 010062290NJ01 | OTHER | NEW JERSEY | ANTHEM HEALTH NETWORK |
| 4 | 48J331 | OTHER | NEW JERSEY | EMPIRE HMO |
| 5 | G10008 | MEDICARE UPIN | NEW JERSEY | |
| 6 | 04833 | MEDICARE ID-TYPE UNSPECIFIED | NEW YORK | NY MEDICARE |
| 7 | 660003068 | OTHER | NEW JERSEY | RAILROAD MEDICARE |
| 8 | CA4003 | OTHER | NEW JERSEY | ATLANTIS HALTH PLAN |
| 9 | 1046529002 | OTHER | NEW JERSEY | CIGNA |
| 10 | 1K5350 | OTHER | NEW JERSEY | HEALTH NET |
| 11 | 2376168 | OTHER | NEW JERSEY | AETNA HMO |
| 12 | 32905 | OTHER | NEW JERSEY | MASTER CARE |
| 13 | 088770 | MEDICARE ID-TYPE UNSPECIFIED | NEW JERSEY | NJ MEDICARE |
| 14 | 1799913 | OTHER | NEW JERSEY | GHI |
| 15 | 354AC1 | OTHER | NEW YORK | EMPIRE ALL PLANS NY |
| 16 | 48J33 | OTHER | NEW JERSEY | EMPIRE PPO |
| 17 | 1K3612 | OTHER | NEW JERSEY | FIRST OPTION |
| 18 | 23161 | OTHER | NEW JERSEY | UNIVERSITY HEALTH PLAN |
| 19 | 7315503 | MEDICAID | NEW JERSEY | |
