Provider Demographics
NPI:1043507270
Name:MEJIA PEDIATRICS LLC
Entity Type:Organization
Organization Name:MEJIA PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GONZALEZ MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-436-1002
Mailing Address - Street 1:433 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3300
Mailing Address - Country:US
Mailing Address - Phone:908-436-1002
Mailing Address - Fax:908-436-1109
Practice Address - Street 1:433 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3300
Practice Address - Country:US
Practice Address - Phone:908-436-1002
Practice Address - Fax:908-436-1109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1428465261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0261181Medicaid