Provider Demographics
NPI:1194439570
Name:TEJADA, JOHNATHAN
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:TEJADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 RIVERSIDE STATION BLVD # 3242
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-4432
Mailing Address - Country:US
Mailing Address - Phone:786-238-1437
Mailing Address - Fax:
Practice Address - Street 1:3242 RIVERSIDE STATION BLVD # 3242
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-4432
Practice Address - Country:US
Practice Address - Phone:786-238-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLT230433840100172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver