Healthcare Provider Details

I. General information

NPI: 1053062539
Provider Name (Legal Business Name): OSTEOPATHIC FAMILY MEDICINE OF NORTHERN NJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 CEDAR HILL AVE
WYCKOFF NJ
07481-2150
US

IV. Provider business mailing address

541 CEDAR HILL AVE STE 2
WYCKOFF NJ
07481-2133
US

V. Phone/Fax

Practice location:
  • Phone: 551-500-5708
  • Fax:
Mailing address:
  • Phone: 551-815-1000
  • Fax: 551-815-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL DEFEO
Title or Position: PHYSICIAN OWNER
Credential: DO
Phone: 551-815-1000