Healthcare Provider Details

I. General information

NPI: 1467610014
Provider Name (Legal Business Name): ANNA HARUTYUNYAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2008
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E RIDGEWOOD AVE BLDG 6, SECOND FLOOR
PARAMUS NJ
07652-4142
US

IV. Provider business mailing address

28 WOODCREST DR
WOODCLIFF LAKE NJ
07677-7628
US

V. Phone/Fax

Practice location:
  • Phone: 201-362-3978
  • Fax:
Mailing address:
  • Phone: 201-362-3978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08285000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0206512
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: