Provider Demographics
NPI:1457349011
Name:PARDES, JORGE GUSTAVO (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:GUSTAVO
Last Name:PARDES
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 8000
Mailing Address - Street 2:DEPT 601
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:866-295-0041
Mailing Address - Fax:708-342-2517
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-923-7700
Practice Address - Fax:732-923-7710
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049953L2085R0202X
NJ25MA083268002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0844459Medicaid
PA483261OtherPA BLUE SHIELD
PA0014226300005Medicaid
NJ0149420Medicaid
PA0014226300005Medicaid
NJ119330Medicare PIN
D04029Medicare UPIN
PA0844459Medicaid