Healthcare Provider Details

I. General information

NPI: 1649198458
Provider Name (Legal Business Name): YONATHAN HAILE-SELASSIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 OLD SHORT HILLS RD
WEST ORANGE NJ
07052-1097
US

IV. Provider business mailing address

51 OLD SHORT HILLS RD
WEST ORANGE NJ
07052-1097
US

V. Phone/Fax

Practice location:
  • Phone: 201-535-4895
  • Fax:
Mailing address:
  • Phone: 201-535-4895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: