Provider Demographics
NPI:1922030196
Name:ISAAC, MICHAEL R
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:ISAAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MICHAEL R. ISAAC
Mailing Address - Street 2:216 PALISADE AVENUE
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306
Mailing Address - Country:US
Mailing Address - Phone:201-459-1177
Mailing Address - Fax:201-459-1199
Practice Address - Street 1:MICHAEL R. ISAAC
Practice Address - Street 2:216 PALISADE AVENUE
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-459-1177
Practice Address - Fax:201-459-1199
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2010-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25M00161901213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1966405Medicaid
T45469Medicare UPIN
NJ1966405Medicaid