Provider Demographics
NPI:1407015373
Name:BAISRE-DE LEON, ADA (MD)
Entity Type:Individual
Prefix:
First Name:ADA
Middle Name:
Last Name:BAISRE-DE LEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 S ORANGE AVE
Mailing Address - Street 2:MSB C557
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2757
Mailing Address - Country:US
Mailing Address - Phone:973-972-7167
Mailing Address - Fax:
Practice Address - Street 1:185 S ORANGE AVE
Practice Address - Street 2:MSB C557
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2757
Practice Address - Country:US
Practice Address - Phone:973-972-7167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08631000207ZP0007X, 207ZN0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology