Healthcare Provider Details

I. General information

NPI: 1982840898
Provider Name (Legal Business Name): ANGELA EFTYCHIADIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MALCOLM AVE
TETERBORO NJ
07608-1011
US

IV. Provider business mailing address

456 PASSAIC AVE
NUTLEY NJ
07110-1752
US

V. Phone/Fax

Practice location:
  • Phone: 201-393-5443
  • Fax: 201-462-4199
Mailing address:
  • Phone: 201-393-5443
  • Fax: 201-462-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number25MA06383000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25MA06383000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: