Healthcare Provider Details

I. General information

NPI: 1841500881
Provider Name (Legal Business Name): BERGEN NEUROLOGY AND PAIN MANAGEMENT PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PAVONIA AVE 3RD FLOOR
JERSEY CITY NJ
07306-2929
US

IV. Provider business mailing address

PO BOX 50
LIVINGSTON NJ
07039-0050
US

V. Phone/Fax

Practice location:
  • Phone: 201-420-1522
  • Fax: 201-420-1633
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number25MA03289800
License Number StateNJ

VIII. Authorized Official

Name: DR. VIJAYA R DASIKA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 973-735-4655