Provider Demographics
NPI:1477555217
Name:BRAZAITIS, DAIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:DAIVA
Middle Name:
Last Name:BRAZAITIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:721-212-0060
Mailing Address - Fax:732-212-0061
Practice Address - Street 1:155 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1706
Practice Address - Country:US
Practice Address - Phone:973-589-1300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25MA07119200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8322104Medicaid
NJ042622Medicare ID - Type Unspecified
NJ8322104Medicaid