Healthcare Provider Details

I. General information

NPI: 1164164802
Provider Name (Legal Business Name): ANDREA RADOSSI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVENUE 4 MAIN
HACKENSACK NJ
07601
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-4466
  • Fax: 551-996-0969
Mailing address:
  • Phone: 551-996-4466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB12642000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: