Provider Demographics
NPI:1225070121
Name:BALDASSARE, JACK LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LAWRENCE
Last Name:BALDASSARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:LAWRENCE
Other - Last Name:BALDASAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:220 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-3118
Mailing Address - Country:US
Mailing Address - Phone:201-567-6156
Mailing Address - Fax:201-871-8708
Practice Address - Street 1:220 OXFORD DR
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-3118
Practice Address - Country:US
Practice Address - Phone:201-567-6156
Practice Address - Fax:201-871-8708
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA36060002085R0202X
NY124001-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00481521Medicaid
NJBA113644OtherMEDICARE ID-TYPE
NJ0864307Medicaid
NY00481521Medicaid
NJ0864307Medicaid
NJB20741Medicare UPIN