Provider Demographics
NPI:1417996836
Name:KLYASHTORNY, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:KLYASHTORNY
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 1:940 AMBOY AVE
Mailing Address - Street 2:SUITE 104-A
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2869
Mailing Address - Country:US
Mailing Address - Phone:732-738-3963
Mailing Address - Fax:732-738-3965
Practice Address - Street 1:940 AMBOY AVE
Practice Address - Street 2:STE 104-A
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2869
Practice Address - Country:US
Practice Address - Phone:732-738-3963
Practice Address - Fax:732-738-3965
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06926200207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG97568Medicare UPIN