Basic Information
| Provider Information | |||||||||
| NPI: | 1053631846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PANDE V. JOSIFOSKI, M.D., L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 HIGHLAND AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | GLEN RIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070281527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737480678 | ||||||||
| FaxNumber: | 9737482808 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 HIGHLAND AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | GLEN RIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070281527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737480678 | ||||||||
| FaxNumber: | 9737482808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2010 | ||||||||
| LastUpdateDate: | 06/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | PALACIOS | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9737480678 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 25MA02629900 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1D1696904 | 05 | NJ | MEDICAID |