Provider Demographics
NPI:1821271776
Name:GARY J FADEN DPM
Entity Type:Organization
Organization Name:GARY J FADEN DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FADEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-458-8383
Mailing Address - Street 1:216 JACK MARTIN BLVD
Mailing Address - Street 2:SUITE D4
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7771
Mailing Address - Country:US
Mailing Address - Phone:732-458-8383
Mailing Address - Fax:732-458-8965
Practice Address - Street 1:216 JACK MARTIN BLVD
Practice Address - Street 2:SUITE D4
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7771
Practice Address - Country:US
Practice Address - Phone:732-458-8383
Practice Address - Fax:732-458-8965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00114700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3888530001Medicare NSC