Provider Demographics
NPI:1720110547
Name:PICHARDO, NELSON R (MD)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:R
Last Name:PICHARDO
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 1:80 PASSAIC AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4860
Mailing Address - Country:US
Mailing Address - Phone:973-928-2167
Mailing Address - Fax:973-928-2170
Practice Address - Street 1:80 PASSAIC AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4860
Practice Address - Country:US
Practice Address - Phone:973-928-2167
Practice Address - Fax:973-928-2170
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2137731207R00000X
NJ25MA03887500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0066885Medicaid
NJC54472Medicare UPIN
NJ0066885Medicaid