=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497071732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAILA DADVAND M.D., PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2010
-----------------------------------------------------
Last Update Date | 06/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 LAUREL HEIGHTS DR
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-455-4800
-----------------------------------------------------
Fax | 856-451-0650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 LAUREL HEIGHTS DR
-----------------------------------------------------
City | BRIDGETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08302-3635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-455-4800
-----------------------------------------------------
Fax | 856-451-0650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA11700100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------