Individual
ROY J FERTAKOS
Active
Individual
ROY J FERTAKOS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
25MA05686200
NJ
2085R0202X
Diagnostic Radiology Physician
Primary
062399L
PA
2085R0202X
Diagnostic Radiology Physician
25MA05686200
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001668701
—
PA
01
—
300110976
RAILROAD MEDICARE - SMC
NJ
05
—
8224005
—
NJ
Enumeration date
09/20/2006
Last updated
09/03/2020
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