Provider Demographics
NPI:1427020718
Name:PRAVDA, DOUGLAS JAN (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAN
Last Name:PRAVDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 WATCHUNG FRK
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-3816
Mailing Address - Country:US
Mailing Address - Phone:908-233-7383
Mailing Address - Fax:
Practice Address - Street 1:622 BOULEVARD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1640
Practice Address - Country:US
Practice Address - Phone:908-241-3181
Practice Address - Fax:908-241-1669
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03272500207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ10664103OtherUNIVERSAL CREDENTIALING
NHUS-292OtherOXFORD INSURANCE
NJ127381096OtherOTHER INSURANCE COMPANIES
NHUS-292OtherOXFORD INSURANCE
NJ152685Medicare PIN