Provider Demographics
NPI:1427020635
Name:FAMILY WELLNESS CENTER PC
Entity Type:Organization
Organization Name:FAMILY WELLNESS CENTER PC
Other - Org Name:FAMILY WELLNESS CENTER, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:DORNFELD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-671-3730
Mailing Address - Street 1:1680 STATE HWY 35
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748
Mailing Address - Country:US
Mailing Address - Phone:732-671-3730
Mailing Address - Fax:732-706-1078
Practice Address - Street 1:1680 STATE HWY 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748
Practice Address - Country:US
Practice Address - Phone:732-671-3730
Practice Address - Fax:732-706-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04895800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5112109Medicaid
E27326Medicare UPIN
NJ574145Medicare ID - Type Unspecified
NJE27326Medicare UPIN
NJ574145-1Medicare PIN