Provider Demographics
NPI:1871594432
Name:FANOUS, VENIS F (MD)
Entity type:Individual
Prefix:DR
First Name:VENIS
Middle Name:F
Last Name:FANOUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 BRUNSWICK WOODS DR
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5601
Mailing Address - Country:US
Mailing Address - Phone:732-238-3883
Mailing Address - Fax:732-238-4826
Practice Address - Street 1:59 BRUNSWICK WOODS DR
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5601
Practice Address - Country:US
Practice Address - Phone:732-238-3883
Practice Address - Fax:732-238-4826
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2023-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 41914207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4058674OtherAETNA
NJ1304305Medicaid
27614OtherUNITED
27614OtherUNITED
142391Medicare ID - Type Unspecified