Basic Information
Provider Information | |||||||||
NPI: | 1841879970 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IDABOLE | ||||||||
FirstName: | JANBECK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AIDABOLOV | ||||||||
OtherFirstName: | JANBECK | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 105 ROCK LEDGE TER | ||||||||
Address2: |   | ||||||||
City: | HALEDON | ||||||||
State: | NJ | ||||||||
PostalCode: | 075081000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738326898 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 176 PALISADE AVE | ||||||||
Address2: |   | ||||||||
City: | JERSEY CITY | ||||||||
State: | NJ | ||||||||
PostalCode: | 073061121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2017958200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2021 | ||||||||
LastUpdateDate: | 04/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.