Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 2080A0000X | Pediatrics | Adolescent Medicine | 25MA03802100 | NEW JERSEY | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 222747589 | OTHER | NEW JERSEY | NCHC EIN |
| 2 | 1740345693 | OTHER | NEW MEXICO | 741 BROADWAY |
| 3 | 1932370483 | OTHER | NEW JERSEY | 101 LUDLOW STREET |
| 4 | 1479407 | MEDICAID | NEW JERSEY | |
| 5 | 15484310901 | OTHER | NEW JERSEY | 982 BROAD STREET |
| 6 | 1194996645 | OTHER | NEW JERSEY | 444 WILLIAM STREET |
