Provider Demographics
NPI:1639283047
Name:LAUREDAN, BERNIER (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNIER
Middle Name:
Last Name:LAUREDAN
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 1:22 BALL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3521
Mailing Address - Country:US
Mailing Address - Phone:973-371-1600
Mailing Address - Fax:973-372-7677
Practice Address - Street 1:22 BALL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3521
Practice Address - Country:US
Practice Address - Phone:973-371-1600
Practice Address - Fax:973-372-7677
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05388700305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0677701Medicaid