Provider Demographics
NPI:1295872661
Name:FAHOURY, GEORGE J JR (DPM)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:J
Last Name:FAHOURY
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:655 SHREWSBURY AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4179
Mailing Address - Country:US
Mailing Address - Phone:732-741-5500
Mailing Address - Fax:732-741-5560
Practice Address - Street 1:655 SHREWSBURY AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702-4179
Practice Address - Country:US
Practice Address - Phone:732-741-5500
Practice Address - Fax:732-741-5560
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01290213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT44727Medicare UPIN
NJ119768Medicare ID - Type Unspecified