Healthcare Provider Details

I. General information

NPI: 1306121504
Provider Name (Legal Business Name): GERIATRICS AND LONGEVITY TREATMENT SPECIALIST, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 MAIN ST
HACKENSACK NJ
07601-4847
US

IV. Provider business mailing address

810 MAIN ST
HACKENSACK NJ
07601-4847
US

V. Phone/Fax

Practice location:
  • Phone: 201-663-7375
  • Fax:
Mailing address:
  • Phone: 201-663-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. STEFANOS G PANTAGIS
Title or Position: OWNER
Credential: MD
Phone: 201-663-7375