Provider Demographics
NPI:1417083403
Name:COLLEGE PLAZA PEDIATRICS
Entity Type:Organization
Organization Name:COLLEGE PLAZA PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-659-9991
Mailing Address - Street 1:765 ROUTE 10 EAST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-1925
Mailing Address - Country:US
Mailing Address - Phone:973-659-9991
Mailing Address - Fax:973-659-9632
Practice Address - Street 1:765 ROUTE 10 EAST
Practice Address - Street 2:SUITE 203
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-1925
Practice Address - Country:US
Practice Address - Phone:973-659-9991
Practice Address - Fax:973-659-9632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA057052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty