Provider Demographics
NPI:1063588481
Name:GAN, RICHARD A (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:GAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:34-36 PROGRESS ST
Mailing Address - Street 2:B-3
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1197
Mailing Address - Country:US
Mailing Address - Phone:908-757-6633
Mailing Address - Fax:908-757-3912
Practice Address - Street 1:34-36 PROGRESS ST
Practice Address - Street 2:B-3
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1197
Practice Address - Country:US
Practice Address - Phone:908-757-6633
Practice Address - Fax:908-757-3912
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA064759002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7039301Medicaid
C47093Medicare UPIN
NJ7039301Medicaid