Healthcare Provider Details

I. General information

NPI: 1922057538
Provider Name (Legal Business Name): FARHAD IDJADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: FARHAD IDJADI M.D.

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 ROUTE 565
SUSSEX NJ
07461-4490
US

IV. Provider business mailing address

1644 ROUTE 565
SUSSEX NJ
07461-4490
US

V. Phone/Fax

Practice location:
  • Phone: 973-875-5718
  • Fax:
Mailing address:
  • Phone: 201-280-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA02473600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: