Provider Demographics
NPI:1164515706
Name:DEDOUSIS, JOHN THOMAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:DEDOUSIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1166 KENNEDY BLVD.
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3112
Mailing Address - Country:US
Mailing Address - Phone:201-339-1133
Mailing Address - Fax:201-339-1073
Practice Address - Street 1:1166 KENNEDY BLVD.
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3112
Practice Address - Country:US
Practice Address - Phone:201-339-1133
Practice Address - Fax:201-339-1073
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA51855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1838903Medicaid
NJ1838903Medicaid
NJ901581Medicare ID - Type Unspecified