Healthcare Provider Details

I. General information

NPI: 1487851903
Provider Name (Legal Business Name): RIDGEWOOD INFECTIOUS DISEASE ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 DAYTON ST SUITE 201
RIDGEWOOD NJ
07450-4496
US

IV. Provider business mailing address

141 DAYTON ST SUITE 201
RIDGEWOOD NJ
07450-4496
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-6468
  • Fax: 201-447-3189
Mailing address:
  • Phone: 201-447-6468
  • Fax: 201-447-3189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA03896800
License Number StateNJ

VIII. Authorized Official

Name: GARY G KNACKMUHS
Title or Position: DELEGATED OFFICIAL
Credential: M.D.
Phone: 201-447-6468