Healthcare Provider Details

I. General information

NPI: 1881750834
Provider Name (Legal Business Name): MICHAEL J FIDANZATO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 EWING ST SUITE C7
PRINCETON NJ
08540-2757
US

IV. Provider business mailing address

10 ADAMS DR
BELLE MEAD NJ
08502-4615
US

V. Phone/Fax

Practice location:
  • Phone: 609-921-7620
  • Fax: 609-921-0869
Mailing address:
  • Phone: 609-921-7620
  • Fax: 609-921-0869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMA54952
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: