Provider Demographics
NPI:1366409310
Name:SEDARAT, ALI (MD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:SEDARAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1311
Mailing Address - Country:US
Mailing Address - Phone:201-343-7272
Mailing Address - Fax:201-343-0228
Practice Address - Street 1:159 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1311
Practice Address - Country:US
Practice Address - Phone:201-343-7272
Practice Address - Fax:201-343-0228
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04745900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3459306Medicaid
NJB90291Medicare UPIN
NJ3459306Medicaid