Provider Demographics
NPI:1437676848
Name:KIDZDOC MD PEDIATRICS LLC
Entity Type:Organization
Organization Name:KIDZDOC MD PEDIATRICS LLC
Other - Org Name:PEDIATRICS ON PROSPECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:HUGH-GOFFE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-732-1718
Mailing Address - Street 1:120 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2103
Mailing Address - Country:US
Mailing Address - Phone:973-732-1718
Mailing Address - Fax:973-732-1719
Practice Address - Street 1:120 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2103
Practice Address - Country:US
Practice Address - Phone:973-732-1718
Practice Address - Fax:973-732-1719
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KIDZDOC MD PEDIATRICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO7567100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty