Healthcare Provider Details

I. General information

NPI: 1760275614
Provider Name (Legal Business Name): EDIE, A DUQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2025
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
STRATFORD NJ
08084-1500
US

IV. Provider business mailing address

8334 263RD ST
FLORAL PARK NY
11004-1712
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-7050
  • Fax:
Mailing address:
  • Phone: 516-492-0237
  • Fax: 516-492-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: