Healthcare Provider Details

I. General information

NPI: 1104136381
Provider Name (Legal Business Name): JEREMY ROBERT MAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 702
HACKENSACK NJ
07601-1974
US

IV. Provider business mailing address

20 PROSPECT AVE STE 702
HACKENSACK NJ
07601-1974
US

V. Phone/Fax

Practice location:
  • Phone: 201-441-9890
  • Fax: 201-441-9893
Mailing address:
  • Phone: 201-441-9890
  • Fax: 201-441-9893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA08756000
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: