Provider Demographics
NPI:1437470119
Name:KIDANGAN, JULIE THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:THOMAS
Last Name:KIDANGAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:M
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 419430
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9430
Mailing Address - Country:US
Mailing Address - Phone:201-666-3900
Mailing Address - Fax:201-261-0505
Practice Address - Street 1:1310 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3010
Practice Address - Country:US
Practice Address - Phone:973-338-0935
Practice Address - Fax:973-338-1097
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09393100207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ332412Medicare PIN