Provider Demographics
NPI:1497137491
Name:FIRST STATE ENT ASSOCIATION INC
Entity Type:Organization
Organization Name:FIRST STATE ENT ASSOCIATION INC
Other - Org Name:FIRST STATE ENT ASSOCIATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAGDEEP
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUNDAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-266-9166
Mailing Address - Street 1:774 CHRISTIANA ROAD
Mailing Address - Street 2:NEUROSCIENCE BUILDING STE B4
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-4236
Mailing Address - Country:US
Mailing Address - Phone:302-266-2449
Mailing Address - Fax:302-266-2450
Practice Address - Street 1:774 CHRISTIANA ROAD
Practice Address - Street 2:NEUROSCIENCE BUILDING STE B4
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4236
Practice Address - Country:US
Practice Address - Phone:302-266-2449
Practice Address - Fax:302-266-2450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10008440207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1467639864Medicaid