Healthcare Provider Details

I. General information

NPI: 1760481493
Provider Name (Legal Business Name): DIAGNOSTIC & CLINICAL CARDIOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 MOUNT PLEASANT AVE
WEST ORANGE NJ
07052-2724
US

IV. Provider business mailing address

375 MOUNT PLEASANT AVE
WEST ORANGE NJ
07052-2724
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-9442
  • Fax: 973-731-2918
Mailing address:
  • Phone: 973-731-9442
  • Fax: 973-731-2918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: MARK BROWN
Title or Position: ADMINISTRATOR
Credential:
Phone: 973-731-9442