Healthcare Provider Details

I. General information

NPI: 1053330647
Provider Name (Legal Business Name): JONATHAN P YRAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 08/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 BRICK BLVD
BRICK NJ
08723-6077
US

IV. Provider business mailing address

478 BRICK BLVD
BRICK NJ
08723-6077
US

V. Phone/Fax

Practice location:
  • Phone: 732-701-4848
  • Fax: 732-701-1469
Mailing address:
  • Phone: 732-701-4848
  • Fax: 732-701-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA07733700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number25MA077337000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: