Provider Demographics
NPI:1841215969
Name:DJEBIYAN, ELI S (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELI
Middle Name:S
Last Name:DJEBIYAN
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 1:140 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-6581
Mailing Address - Country:US
Mailing Address - Phone:201-569-9010
Mailing Address - Fax:201-569-9063
Practice Address - Street 1:140 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-6581
Practice Address - Country:US
Practice Address - Phone:201-569-9010
Practice Address - Fax:201-569-9063
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06812100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7706901Medicaid
NJ7706901Medicaid
NJ011787Medicare ID - Type Unspecified