Provider Demographics
NPI:1023268976
Name:BERGEN ENDOCRINOLOGY, PC
Entity type:Organization
Organization Name:BERGEN ENDOCRINOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:YESHOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-281-7835
Mailing Address - Street 1:560 CLINTON RD
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652
Mailing Address - Country:US
Mailing Address - Phone:201-967-8425
Mailing Address - Fax:201-263-4665
Practice Address - Street 1:12-04 SADDLE RIVER RD
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5811
Practice Address - Country:US
Practice Address - Phone:201-773-8710
Practice Address - Fax:201-773-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08384100207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0190861Medicaid
NJ0190861Medicaid