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General NPI Number Information
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NPI Number | 1891752648
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Entity Type | Individual
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Provider Name | EDMUNDO C DE VERA MD
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Gender | Male
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Dates
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Enumeration Date | 04/26/2006
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Last Update Date | 03/14/2012
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Provider Practice Location Address
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Address Line | 5301 BROADWAY
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City | WEST NEW YORK
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State | NJ
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Zip | 07093-2622
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Country | US
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Telephone | 201-866-9320
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Fax |
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Provider Business Mailing Address
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Address Line | 211 W ELMWOOD DR
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City | SOUTH PLAINFIELD
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State | NJ
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Zip | 07080-4914
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Country | US
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Telephone | 908-755-9731
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MAO 61048
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License Number State | NJ
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