Provider Demographics
NPI:1235275561
Name:SADEGHI, HOOSHANG (MD)
Entity Type:Individual
Prefix:
First Name:HOOSHANG
Middle Name:
Last Name:SADEGHI
Suffix:
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:PO BOX 4302
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-0302
Mailing Address - Country:US
Mailing Address - Phone:201-823-2888
Mailing Address - Fax:201-823-2880
Practice Address - Street 1:631 BROADWAY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3846
Practice Address - Country:US
Practice Address - Phone:201-823-2888
Practice Address - Fax:201-823-2880
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA29197174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3642003Medicaid
NJ033022Medicare ID - Type Unspecified
NJ3642003Medicaid