Provider Demographics
NPI:1275126211
Name:PRINCETON MEDICAL & AESTHETICS CENTER LLC
Entity Type:Organization
Organization Name:PRINCETON MEDICAL & AESTHETICS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:
Authorized Official - Last Name:JETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-874-0070
Mailing Address - Street 1:61 PRINCETON HIGHTSTOWN RD # 2C
Mailing Address - Street 2:
Mailing Address - City:PRINCETON JUNCTION
Mailing Address - State:NJ
Mailing Address - Zip Code:08550-1120
Mailing Address - Country:US
Mailing Address - Phone:609-874-0070
Mailing Address - Fax:609-874-0029
Practice Address - Street 1:61 PRINCETON HIGHTSTOWN RD # 2C
Practice Address - Street 2:
Practice Address - City:PRINCETON JUNCTION
Practice Address - State:NJ
Practice Address - Zip Code:08550-1120
Practice Address - Country:US
Practice Address - Phone:609-874-0070
Practice Address - Fax:609-874-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty