Provider Demographics
NPI:1922151315
Name:JOHN T. DEDOUSIS, MD, P. C.
Entity Type:Organization
Organization Name:JOHN T. DEDOUSIS, MD, P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DEDOUSIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-339-1133
Mailing Address - Street 1:1166 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3112
Mailing Address - Country:US
Mailing Address - Phone:201-339-1133
Mailing Address - Fax:201-339-1073
Practice Address - Street 1:1166 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3112
Practice Address - Country:US
Practice Address - Phone:201-339-1133
Practice Address - Fax:201-339-1073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1838903Medicaid
NJC56917Medicare UPIN
NJ1838903Medicaid