Healthcare Provider Details

I. General information

NPI: 1497916845
Provider Name (Legal Business Name): UMER DASTI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 04/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 S MAPLE AVE
RIDGEWOOD NJ
07450-4561
US

IV. Provider business mailing address

85 S MAPLE AVE
RIDGEWOOD NJ
07450-4561
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-2830
  • Fax: 201-445-7471
Mailing address:
  • Phone: 201-445-2830
  • Fax: 201-445-7471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number25MA09298900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA09298900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: