Healthcare Provider Details

I. General information

NPI: 1720047525
Provider Name (Legal Business Name): LUCIAN V DAJDEA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6685 FOREST AVENUE FOREST MEDICAL PC
RIDGEWOOD NY
11385
US

IV. Provider business mailing address

6685 FOREST AVENUE FOREST MEDICAL PC
RIDGEWOOD NY
11385
US

V. Phone/Fax

Practice location:
  • Phone: 718-456-9733
  • Fax: 718-418-2547
Mailing address:
  • Phone: 718-456-9733
  • Fax: 718-418-2547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number153356
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: