1326496241 NPI number — NJ CERTIFIED DERMATOLOGY PC

Table of content: (NPI 1326496241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326496241 NPI number — NJ CERTIFIED DERMATOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NJ CERTIFIED DERMATOLOGY PC
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:
6
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:
1326496241
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1580 LAKEWOOD RD STE 16
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOMS RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08755-3287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-456-7777
Provider Business Mailing Address Fax Number:
848-251-2189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2895 HAMILTON BLVD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALLENTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18104-6172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-456-7777
Provider Business Practice Location Address Fax Number:
848-251-2189
Provider Enumeration Date:
06/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
LAWRENCE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
903-521-6143

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103608008 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 773906 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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