Provider Demographics
NPI:1417955238
Name:NATHAN, GERALD ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ROBERT
Last Name:NATHAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07422-1606
Mailing Address - Country:US
Mailing Address - Phone:973-764-7961
Mailing Address - Fax:973-764-9700
Practice Address - Street 1:350 SPARTA AVE
Practice Address - Street 2:STE C-8
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1150
Practice Address - Country:US
Practice Address - Phone:973-729-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-09-13
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
NJ3SSI00276200103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ729911Medicare PIN