Healthcare Provider Details

I. General information

NPI: 1093891723
Provider Name (Legal Business Name): ROBERT PALACIOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 BROAD ST
CLIFTON NJ
07013-3346
US

IV. Provider business mailing address

1135 BROAD ST
CLIFTON NJ
07013-3346
US

V. Phone/Fax

Practice location:
  • Phone: 973-614-0990
  • Fax: 973-614-8288
Mailing address:
  • Phone: 973-614-0990
  • Fax: 973-614-8288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA05626700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: