Healthcare Provider Details

I. General information

NPI: 1487753497
Provider Name (Legal Business Name): RAMON MODESTO TALLAJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 ACADEMY STREET
NEW YORK NY
10034
US

IV. Provider business mailing address

25 CLARKSON CT.
PARAMUS NJ
07652
US

V. Phone/Fax

Practice location:
  • Phone: 212-567-0550
  • Fax:
Mailing address:
  • Phone: 212-567-0550
  • Fax: 212-567-6574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number204704
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: