Healthcare Provider Details

I. General information

NPI: 1679260780
Provider Name (Legal Business Name): AMANDA ZHAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SEYMOUR ST
MONTCLAIR NJ
07042-3771
US

IV. Provider business mailing address

132 ARLINGTON BLVD
NORTH ARLINGTON NJ
07031-5731
US

V. Phone/Fax

Practice location:
  • Phone: 973-302-9620
  • Fax:
Mailing address:
  • Phone: 862-324-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB12876900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: