Provider Demographics
NPI:1467544015
Name:WALID J. BADDOURA M.D.,P.A.
Entity Type:Organization
Organization Name:WALID J. BADDOURA M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BADDOURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-777-7733
Mailing Address - Street 1:716 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1645
Mailing Address - Country:US
Mailing Address - Phone:973-777-7733
Mailing Address - Fax:973-777-0669
Practice Address - Street 1:716 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1645
Practice Address - Country:US
Practice Address - Phone:973-777-7733
Practice Address - Fax:973-777-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA33827207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3075001Medicaid
NJ460407Medicare ID - Type Unspecified
NJ3075001Medicaid