Healthcare Provider Details

I. General information

NPI: 1972655322
Provider Name (Legal Business Name): ALEXANDER ZODIATIS D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 02/18/2023
Certification Date: 02/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178 COOMBS DR
PARAMUS NJ
07652-4435
US

IV. Provider business mailing address

178 COOMBS DR
PARAMUS NJ
07652-4435
US

V. Phone/Fax

Practice location:
  • Phone: 908-509-4894
  • Fax: 973-595-0206
Mailing address:
  • Phone: 347-661-5924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MB08130000
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: