Provider Demographics
NPI:1558337972
Name:ISIDRO, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ISIDRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 NEW BROOKLYN RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2254
Mailing Address - Country:US
Mailing Address - Phone:732-318-6869
Mailing Address - Fax:732-494-9112
Practice Address - Street 1:2 LINCOLN HWY
Practice Address - Street 2:# 109
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3961
Practice Address - Country:US
Practice Address - Phone:732-318-6869
Practice Address - Fax:732-494-9112
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-25
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04749000207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4536908Medicaid
NJ4536908Medicaid
NJ670502Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER