=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962457366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALI DANESHVAR M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 W OAKCREST AVE
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-646-7000
-----------------------------------------------------
Fax | 609-646-7140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 CAMBRIDGE AVE
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 25MA05615600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------