Provider Demographics
NPI:1205040425
Name:KASHLAN, FAWAZ
Entity Type:Individual
Prefix:
First Name:FAWAZ
Middle Name:
Last Name:KASHLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 WEST GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 SPRINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-3727
Practice Address - Country:US
Practice Address - Phone:732-922-4763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA062032002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7401906Medicaid
NJ004820Medicare PIN