Healthcare Provider Details

I. General information

NPI: 1700022027
Provider Name (Legal Business Name): MARJORIE ALDERETE GAYANILO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 TEANECK RD
TEANECK NJ
07666-4245
US

IV. Provider business mailing address

3 UNIVERSITY PLZ STE 205
HACKENSACK NJ
07601-6208
US

V. Phone/Fax

Practice location:
  • Phone: 201-833-3535
  • Fax:
Mailing address:
  • Phone: 201-833-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number247429
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number4301106902
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number25MA09354400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0384143
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: