Provider Demographics
NPI:1760594576
Name:GONT, ROMAN (CHIROPRACTOR)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:GONT
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13-51 B RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-398-0020
Mailing Address - Fax:201-398-0029
Practice Address - Street 1:13-51 B RIVER RD
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410
Practice Address - Country:US
Practice Address - Phone:201-398-0020
Practice Address - Fax:201-398-0029
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00573700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ045239SBYMedicare ID - Type UnspecifiedMEDICARE PERSONAL NUMBER
NJ075551Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER