Provider Demographics
NPI:1386680635
Name:YOUSSEF, JAN SAMIR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:SAMIR
Last Name:YOUSSEF
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 1:115 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2924
Mailing Address - Country:US
Mailing Address - Phone:973-773-9250
Mailing Address - Fax:973-773-9525
Practice Address - Street 1:115 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2924
Practice Address - Country:US
Practice Address - Phone:973-773-9250
Practice Address - Fax:973-773-9525
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07328900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0037109Medicaid
NJ081570Medicare ID - Type Unspecified
NJ0037109Medicaid
NJ075875Medicare PIN