Basic Information
| Provider Information | |||||||||
| NPI: | 1639115819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABUD | ||||||||
| FirstName: | ALFREDO | ||||||||
| MiddleName: | RAMON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8500-8582 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191788582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098157810 | ||||||||
| FaxNumber: | 6098157814 | ||||||||
| Practice Location | |||||||||
| Address1: | 832 BRUNSWICK AVE | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086383847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093946012 | ||||||||
| FaxNumber: | 6095376002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 25MA03600000 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0103654000 | 01 | AMERI HEALTH | OTHER | 95983785C | 05 | NJ | MEDICAID | F17068 | 01 | HEALTHNET | OTHER | 133821 | 01 | CHN | OTHER | 24723 | 01 | AMERI GROUP | OTHER |