Provider Demographics
NPI:1407871700
Name:ROMAN, EDWIN R (DPM)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:R
Last Name:ROMAN
Suffix:
Gender:M
Credentials:DPM
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 493
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07207-0493
Mailing Address - Country:US
Mailing Address - Phone:908-352-1400
Mailing Address - Fax:908-352-7900
Practice Address - Street 1:430 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3609
Practice Address - Country:US
Practice Address - Phone:908-352-1400
Practice Address - Fax:908-352-7900
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00283800213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0084328Medicaid
NJ095340Medicare PIN