Healthcare Provider Details

I. General information

NPI: 1407350101
Provider Name (Legal Business Name): KOOROSH NEMATI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 05/15/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 OLD SHORT HILLS RD STE 408
WEST ORANGE NJ
07052-1023
US

IV. Provider business mailing address

379 CAMPUS DR FL 4
SOMERSET NJ
08873-1161
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-6600
  • Fax:
Mailing address:
  • Phone: 732-937-8939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA12114400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number25MA12114400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: