Provider Demographics
NPI:1295392108
Name:BOMFIM, SUSANNA (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:
Last Name:BOMFIM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:
Other - Last Name:WOOLSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:973-577-5825
Mailing Address - Fax:
Practice Address - Street 1:800 MORRIS TPKE
Practice Address - Street 2:
Practice Address - City:SHORT HILLS
Practice Address - State:NJ
Practice Address - Zip Code:07078-2698
Practice Address - Country:US
Practice Address - Phone:908-273-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11136600207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine