=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457150492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT DESIMONE FUNCTIONAL MEDICINE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2025
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 254 COLUMBIA TPKE STE 200
-----------------------------------------------------
City | FLORHAM PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07932-1225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-886-2195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 508
-----------------------------------------------------
City | MONTVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07045-0508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-886-2195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT ANTHONY DESIMONE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-886-2195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------