Healthcare Provider Details

I. General information

NPI: 1508128224
Provider Name (Legal Business Name): MEDICAL DIAGNOSTIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BEAUVOIR AVE
SUMMIT NJ
07901-3533
US

IV. Provider business mailing address

77 BRANT AVE SUITE 200
CLARK NJ
07066-1560
US

V. Phone/Fax

Practice location:
  • Phone: 908-608-1504
  • Fax: 908-608-0078
Mailing address:
  • Phone: 732-382-0091
  • Fax: 732-382-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number25MA06949800
License Number StateNJ

VIII. Authorized Official

Name: TERRY DYER
Title or Position: PRACTICE ADMINISTRATOR
Credential: CMPE
Phone: 732-382-0091