Provider Demographics
NPI:1154380996
Name:OTRAKJI, JEAN A (MD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:A
Last Name:OTRAKJI
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 1:721 N BEERS ST
Mailing Address - Street 2:SUITE 1-F
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1518
Mailing Address - Country:US
Mailing Address - Phone:732-888-9100
Mailing Address - Fax:732-888-5515
Practice Address - Street 1:721 N BEERS ST
Practice Address - Street 2:SUITE 1-F
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1518
Practice Address - Country:US
Practice Address - Phone:732-888-9100
Practice Address - Fax:732-888-5515
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04735600207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3266206Medicaid
NJ443225C2LMedicare ID - Type Unspecified
NJC54639Medicare UPIN