Provider Demographics
NPI:1124055116
Name:KHALADJ, MORTEZA (PODIATRIST DPM)
Entity type:Individual
Prefix:MR
First Name:MORTEZA
Middle Name:
Last Name:KHALADJ
Suffix:
Gender:M
Credentials:PODIATRIST DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:NJ
Mailing Address - Zip Code:07934
Mailing Address - Country:US
Mailing Address - Phone:908-625-1042
Mailing Address - Fax:908-355-4400
Practice Address - Street 1:9 LAMINGTON RD
Practice Address - Street 2:
Practice Address - City:BRANCHBURG
Practice Address - State:NJ
Practice Address - Zip Code:08876
Practice Address - Country:US
Practice Address - Phone:908-625-1042
Practice Address - Fax:908-355-4400
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00179900213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1442902Medicaid
NJ1442902Medicaid