Healthcare Provider Details

I. General information

NPI: 1679991145
Provider Name (Legal Business Name): JASON ANTHONY KRYSTOFIAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S ORANGE AVE STE 118
LIVINGSTON NJ
07039-5817
US

IV. Provider business mailing address

200 S ORANGE AVE STE 118
LIVINGSTON NJ
07039-5817
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-7330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA09978800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: