Provider Demographics
NPI:1417282922
Name:J CALVIN CHATLOS MD LLC
Entity Type:Organization
Organization Name:J CALVIN CHATLOS MD LLC
Other - Org Name:JOHN C CHATLOS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:CHATLOS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:732-414-6001
Mailing Address - Street 1:400 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2529
Mailing Address - Country:US
Mailing Address - Phone:732-414-6001
Mailing Address - Fax:732-677-3149
Practice Address - Street 1:400 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2529
Practice Address - Country:US
Practice Address - Phone:732-414-6001
Practice Address - Fax:732-677-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 462622084A0401X, 2084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2508206Medicaid
NJC05929Medicare UPIN
NJCH584569Medicare PIN