Individual
DR. JACK LAWRENCE BALDASSARE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
220 OXFORD DR, TENAFLY, NJ 07670-3118
(201) 567-6156
(201) 871-8708
Mailing address
220 OXFORD DR, TENAFLY, NJ 07670-3118
(201) 567-6156
(201) 871-8708
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
124001-1
NY
2085R0202X
Diagnostic Radiology Physician
Primary
25MA3606000
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00481521
—
NY
05
—
0864307
—
NJ
01
—
BA113644
MEDICARE ID-TYPE
NJ
Enumeration date
06/12/2006
Last updated
12/15/2009
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