Provider Demographics
NPI:1932112760
Name:WASSERMAN, KENNETH H (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S VAN BRUNT ST
Mailing Address - Street 2:STE 402
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-567-1140
Mailing Address - Fax:201-567-1998
Practice Address - Street 1:401 S VAN BRUNT ST
Practice Address - Street 2:STE 402
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-567-1140
Practice Address - Fax:201-567-1998
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA43611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B19412Medicare UPIN
NJ535269Medicare ID - Type Unspecified