Basic Information
| Provider Information | |||||||||
| NPI: | 1083671457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JESDANUN | ||||||||
| FirstName: | ADISAK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 387 | ||||||||
| Address2: | |||||||||
| City: | FORDS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088630387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328264177 | ||||||||
| FaxNumber: | 7326071160 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 MAY ST | ||||||||
| Address2: | MAY STREET ANESTHESIA | ||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328264177 | ||||||||
| FaxNumber: | 7326071160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MA26298 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 2370506 | 05 | NJ | MEDICAID |