Provider Demographics
NPI:1063132819
Name:BALIDEMAJ, DONJETA
Entity type:Individual
Prefix:
First Name:DONJETA
Middle Name:
Last Name:BALIDEMAJ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 UPPER FERNDALE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-2016
Mailing Address - Country:US
Mailing Address - Phone:347-854-5933
Mailing Address - Fax:
Practice Address - Street 1:20 W 22ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-5804
Practice Address - Country:US
Practice Address - Phone:646-558-9846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007127171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist