Provider Demographics
NPI:1720047525
Name:DAJDEA, LUCIAN V (MD)
Entity Type:Individual
Prefix:
First Name:LUCIAN
Middle Name:V
Last Name:DAJDEA
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 1:6685 FOREST AVENUE
Mailing Address - Street 2:FOREST MEDICAL PC
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-456-9733
Mailing Address - Fax:718-418-2547
Practice Address - Street 1:6685 FOREST AVENUE
Practice Address - Street 2:FOREST MEDICAL PC
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385
Practice Address - Country:US
Practice Address - Phone:718-456-9733
Practice Address - Fax:718-418-2547
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153356208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
153356OtherHIP
0056085OtherGHI
12D481OtherBCBS
DP008OtherOXF
4C3684OtherHEALTHNET
6604339004OtherCIGNA
4117285OtherAETNA
NY00811945Medicaid
NY00811945Medicaid