Basic Information
Provider Information | |||||||||
NPI: | 1891846234 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VEYSMAN | ||||||||
FirstName: | BORIS | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3681 ROUTE 9 N | ||||||||
Address2: |   | ||||||||
City: | FREEHOLD | ||||||||
State: | NJ | ||||||||
PostalCode: | 077282674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7328637100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 ROBERT WOOD JOHNSON PL | ||||||||
Address2: | MEB ROOM 104 | ||||||||
City: | NEW BRUNSWICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 089011928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322358717 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/14/2007 | ||||||||
LastUpdateDate: | 08/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA08202500 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207P00000X | 25MA08202500 | NJ | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0129569 | 05 | NJ |   | MEDICAID |