Healthcare Provider Details

I. General information

NPI: 1295806123
Provider Name (Legal Business Name): IRA GOUTERMAN M.D., PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WESTVILLE AVE
CALDWELL NJ
07006-5602
US

IV. Provider business mailing address

30 WESTVILLE AVE
CALDWELL NJ
07006-5602
US

V. Phone/Fax

Practice location:
  • Phone: 973-228-6866
  • Fax: 973-228-4133
Mailing address:
  • Phone: 973-228-6866
  • Fax: 973-228-4133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMA035818
License Number StateNJ

VIII. Authorized Official

Name: IRA HERMAN GOUTERMAN
Title or Position: PRESIDENT
Credential: M.D
Phone: 973-228-6866