Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2013-10-23
- Last updated
- 2023-05-25
Licenses
- License NJ
- 37LC00252400
- License NJ
- 44SC05688800
Location
- Practice location
- 80 W MAIN ST
- City
- MENDHAM NJ
- Postal code
- 079451257
- Phone
- 973-543-5656
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.