Healthcare Provider Details

I. General information

NPI: 1194729475
Provider Name (Legal Business Name): CYRUS VOSOUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 HAMBURG TPKE STE B105
WAYNE NJ
07470-2011
US

IV. Provider business mailing address

PO BOX 43092
UPPER MONTCLAIR NJ
07043-0092
US

V. Phone/Fax

Practice location:
  • Phone: 973-595-0063
  • Fax: 973-240-8990
Mailing address:
  • Phone: 973-595-0063
  • Fax: 973-720-0408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMA070629
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: