Provider Demographics
NPI:1174616064
Name:LATIF, PERVAIZE (MD FACA)
Entity type:Individual
Prefix:
First Name:PERVAIZE
Middle Name:
Last Name:LATIF
Suffix:
Gender:M
Credentials:MD FACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 NEW BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863
Mailing Address - Country:US
Mailing Address - Phone:732-738-8000
Mailing Address - Fax:732-738-1663
Practice Address - Street 1:565 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863
Practice Address - Country:US
Practice Address - Phone:732-738-8000
Practice Address - Fax:732-738-1663
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA033090207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1614908Medicaid
NJ6525601Medicaid
A66130Medicare UPIN
NJ1614908Medicaid
755517Medicare ID - Type UnspecifiedGROUP