=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629081013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JON PAUL DADAIAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 04/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 554 BOULEVARD
-----------------------------------------------------
City | ELMWOOD PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-365-5844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 554 BOULEVARD
-----------------------------------------------------
City | ELMWOOD PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07407-3441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 974-204-2645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 25MA08092000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 25MA08092000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------