Provider Demographics
NPI:1124417639
Name:DEWI S. SUDJONO-SANTOSO
Entity Type:Organization
Organization Name:DEWI S. SUDJONO-SANTOSO
Other - Org Name:SAME AS ABOVE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEWI
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUDJONO-SANTOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-918-1030
Mailing Address - Street 1:339 PRINCETON-HIGHTSTOWN RD
Mailing Address - Street 2:BUILDING B
Mailing Address - City:CRANBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08512
Mailing Address - Country:US
Mailing Address - Phone:609-918-1030
Mailing Address - Fax:609-918-1322
Practice Address - Street 1:339 PRINCETON-HIGHTSTOWN RD
Practice Address - Street 2:BUILDING B
Practice Address - City:CRANBURY
Practice Address - State:NJ
Practice Address - Zip Code:08512
Practice Address - Country:US
Practice Address - Phone:609-918-1030
Practice Address - Fax:609-918-1322
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEWI S. SUDJONO-SANTOSO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA015133002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1053342865Medicaid