Provider Demographics
NPI:1518051721
Name:LARDIZABAL, ALFRED A (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:A
Last Name:LARDIZABAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 WARREN ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-3535
Practice Address - Country:US
Practice Address - Phone:973-972-6232
Practice Address - Fax:973-972-3832
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06188100207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6690602Medicaid
NJG15614Medicare UPIN
NJ801396Medicare PIN