Provider Demographics
NPI:1215080163
Name:TANZER, IRA D (MD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:D
Last Name:TANZER
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:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-0250
Mailing Address - Country:US
Mailing Address - Phone:201-867-1297
Mailing Address - Fax:201-867-4165
Practice Address - Street 1:110 MEADOWLANDS PKWY # B
Practice Address - Street 2:SUITE 302
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2302
Practice Address - Country:US
Practice Address - Phone:201-867-1297
Practice Address - Fax:201-867-4165
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA030534174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1425901Medicaid
NJ1425901Medicaid