Provider Demographics
NPI:1780677443
Name:DAFTARI, AMITA (MD)
Entity Type:Individual
Prefix:
First Name:AMITA
Middle Name:
Last Name:DAFTARI
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:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-0067
Mailing Address - Country:US
Mailing Address - Phone:201-487-7227
Mailing Address - Fax:
Practice Address - Street 1:1000 GALLOPING HILL RD
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7951
Practice Address - Country:US
Practice Address - Phone:908-851-8346
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05037700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8674108Medicaid
NJ027198Medicare ID - Type Unspecified
NJ8674108Medicaid