Healthcare Provider Details

I. General information

NPI: 1366409310
Provider Name (Legal Business Name): ALI SEDARAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 SUMMIT AVE
HACKENSACK NJ
07601-1311
US

IV. Provider business mailing address

159 SUMMIT AVE
HACKENSACK NJ
07601-1311
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-7272
  • Fax: 201-343-0228
Mailing address:
  • Phone: 201-343-7272
  • Fax: 201-343-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA04745900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3459306
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: