Provider Demographics
NPI:1508073016
Name:FODA FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:FODA FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:FODA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-985-9100
Mailing Address - Street 1:1939 MARLTON PIKE E STE 250
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-4507
Mailing Address - Country:US
Mailing Address - Phone:856-985-9106
Mailing Address - Fax:609-228-7604
Practice Address - Street 1:1939 MARLTON PIKE E STE 250
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-4507
Practice Address - Country:US
Practice Address - Phone:856-985-9106
Practice Address - Fax:609-228-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07595300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0023442Medicaid
NJ078877Medicare ID - Type Unspecified
NJ0023442Medicaid