Basic Information
| Provider Information | |||||||||
| NPI: | 1457349011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PARDES | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | GUSTAVO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8000 | ||||||||
| Address2: | DEPT 601 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662950041 | ||||||||
| FaxNumber: | 7083422517 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BRANCH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077406303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329237700 | ||||||||
| FaxNumber: | 7329237710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 10/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD049953L | PA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA08326800 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0844459 | 05 | PA | MEDICAID | 483261 | 01 | PA | PA BLUE SHIELD | OTHER | 0014226300005 | 05 | PA | MEDICAID | 0149420 | 05 | NJ | MEDICAID |