Healthcare Provider Details

I. General information

NPI: 1104823921
Provider Name (Legal Business Name): JULIAN ENTRADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 MARTIN LUTHER KING JR BLVD
NEWARK NJ
07102-2011
US

IV. Provider business mailing address

PO BOX 1593
SECAUCUS NJ
07096-1593
US

V. Phone/Fax

Practice location:
  • Phone: 973-877-5034
  • Fax: 973-877-5231
Mailing address:
  • Phone: 201-635-1003
  • Fax: 201-635-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA03175300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA31753
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: