Healthcare Provider Details

I. General information

NPI: 1477573814
Provider Name (Legal Business Name): JASJIT WALIA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 DICKINSON ST
ELIZABETH NJ
07201-2210
US

IV. Provider business mailing address

1150 DICKINSON ST
ELIZABETH NJ
07201-2210
US

V. Phone/Fax

Practice location:
  • Phone: 908-354-8900
  • Fax: 908-354-0007
Mailing address:
  • Phone: 908-354-8900
  • Fax: 908-354-0007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA065019
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: