Basic Information
| Provider Information | |||||||||
| NPI: | 1639445539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ISEDEH | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | ODUJE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 LYONS AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739267000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 YORK STREET, CB-2041 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065143220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884748 | ||||||||
| FaxNumber: | 2036884740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2012 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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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 | 208M00000X | 25MA09458100 | NJ | N | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 62045 | CT | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1639445539 | 05 | VA | MEDICAID | FI4336219 | 01 | VA | DEA | OTHER | 1639445539 | 01 | VA | NPI | OTHER |