Provider Demographics
NPI:1932852654
Name:RESTREPO, JORGE IVAN (PHD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:IVAN
Last Name:RESTREPO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07502-2027
Mailing Address - Country:US
Mailing Address - Phone:407-709-5668
Mailing Address - Fax:
Practice Address - Street 1:221 MAIN ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-1733
Practice Address - Country:US
Practice Address - Phone:973-773-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04144500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist