Provider Demographics
NPI:1710907019
Name:GOTTDIENER, ALEXANDRA H (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:H
Last Name:GOTTDIENER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 ENGLE STREET
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-894-3690
Mailing Address - Fax:
Practice Address - Street 1:350 ENGLE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-894-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07251200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8676801Medicaid
NJ8676801Medicaid
NJ053026Medicare ID - Type Unspecified