Provider Demographics
NPI:1023093564
Name:SECOY, JOHN WALTON (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:SECOY
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:PO BOX 35088
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07193-5088
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:
Practice Address - Street 1:185 FAIRFIELD AVE
Practice Address - Street 2:2A
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-6426
Practice Address - Country:US
Practice Address - Phone:973-226-1230
Practice Address - Fax:973-226-1232
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05646400207L00000X
NJMA56464207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5070309Medicaid
F29106Medicare UPIN
NJ725433DFHMedicare PIN