Provider Demographics
NPI:1982956124
Name:NOUSHIN HEIDARY MD LLC
Entity Type:Organization
Organization Name:NOUSHIN HEIDARY MD LLC
Other - Org Name:DERMATOLOGY AND LASER CENTER OF NORTHERN NEW JERSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NOUSHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIDARY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-740-0101
Mailing Address - Street 1:290 S LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-3931
Mailing Address - Country:US
Mailing Address - Phone:973-740-0101
Mailing Address - Fax:973-740-0103
Practice Address - Street 1:290 S LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-3931
Practice Address - Country:US
Practice Address - Phone:973-740-0101
Practice Address - Fax:973-740-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA98581800207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty