Provider Demographics
NPI:1568828309
Name:BADER, IAN ADAM
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:ADAM
Last Name:BADER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-1216
Mailing Address - Country:US
Mailing Address - Phone:914-793-3933
Mailing Address - Fax:914-793-4751
Practice Address - Street 1:2290 CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-1216
Practice Address - Country:US
Practice Address - Phone:914-793-3933
Practice Address - Fax:914-793-4751
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist