Provider Demographics
NPI:1942505912
Name:LUIS A. YEROVI MD PA
Entity Type:Organization
Organization Name:LUIS A. YEROVI MD PA
Other - Org Name:LUIS A. YEROVI MD PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:YEROVI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:973-344-7676
Mailing Address - Street 1:91 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-1879
Mailing Address - Country:US
Mailing Address - Phone:973-344-7676
Mailing Address - Fax:973-690-5109
Practice Address - Street 1:91 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1879
Practice Address - Country:US
Practice Address - Phone:973-344-7676
Practice Address - Fax:973-690-5109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05714900302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6490107Medicaid
NJ6490107Medicaid