1780894428 NPI number — DERMATOLOGY AND LASER CENTER PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780894428 NPI number — DERMATOLOGY AND LASER CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY AND LASER CENTER PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780894428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 18751
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07191-8751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-222-8323
Provider Business Mailing Address Fax Number:
732-870-9488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
279 THIRD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 603
Provider Business Practice Location Address City Name:
LONG BRANCH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07740-6205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-222-8323
Provider Business Practice Location Address Fax Number:
732-870-9488
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
732-222-8323

Provider Taxonomy Codes

  • Taxonomy code: 207NS0135X , with the licence number:  25MA06221000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0675790000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com