Provider Demographics
NPI:1295745263
Name:FADEN, GARY J (DPM)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:J
Last Name:FADEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:216 JACK MARTIN BLVD
Mailing Address - Street 2:SUITE D-4
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7771
Mailing Address - Country:US
Mailing Address - Phone:732-458-8383
Mailing Address - Fax:732-458-8965
Practice Address - Street 1:216 JACK MARTIN BLVD
Practice Address - Street 2:SUITE D-4
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7771
Practice Address - Country:US
Practice Address - Phone:732-458-8383
Practice Address - Fax:732-458-8965
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00114700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ205671OtherUNIFORMED SERVICES
NJ222332380OtherTAX ID#
NJP404738OtherOXFORD
NJ3011402Medicaid
NJ3011402Medicaid
NJ205671OtherUNIFORMED SERVICES
NJ3888530001Medicare NSC