Provider Demographics
NPI:1619361383
Name:DIABETES ENDCOCRINOLOGY METABOLISM SPEC
Entity Type:Organization
Organization Name:DIABETES ENDCOCRINOLOGY METABOLISM SPEC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-471-2692
Mailing Address - Street 1:6 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1647
Mailing Address - Country:US
Mailing Address - Phone:973-471-2692
Mailing Address - Fax:973-470-8188
Practice Address - Street 1:6 BRIGHTON RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1647
Practice Address - Country:US
Practice Address - Phone:973-471-2692
Practice Address - Fax:973-470-8188
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIABETES ENDCOCRINOLOGY METABOLISM SPEC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207R00000X207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty