Provider Demographics
NPI:1932142957
Name:MALDONADO, JOSE OMAR (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:OMAR
Last Name:MALDONADO
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 1:5301 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2622
Mailing Address - Country:US
Mailing Address - Phone:201-210-0200
Mailing Address - Fax:201-867-9183
Practice Address - Street 1:5301 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2622
Practice Address - Country:US
Practice Address - Phone:201-866-7721
Practice Address - Fax:201-867-9183
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61477208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6509509Medicaid