MEDICARE: DR. OMID DARDASHTI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	25MA08190200	NJ

General Provider Information

NPI Number	:	1639295686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMID DARDASHTI M.D.

Provider Business Mailing Address
First Line	:	1541 LEMOINE AVE
Second Line	:	APT. 2E
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5649
Country	:	US
Telephone Number	:	201-638-6617
Fax Number	:

Provider Business Practice Location Address
First Line	:	297 LAFAYETTE AVE
Second Line	:
City	:	HAWTHORNE
State	:	NJ
Zip	:	07506-1919
Country	:	US
Telephone Number	:	201-439-2625
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/08/2007

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