Provider Demographics
NPI:1508867235
Name:GOLLOUB, CORY ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:ALAN
Last Name:GOLLOUB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9729
Mailing Address - Country:US
Mailing Address - Phone:973-334-9404
Mailing Address - Fax:973-334-7615
Practice Address - Street 1:329 MAIN RD
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9729
Practice Address - Country:US
Practice Address - Phone:973-334-9404
Practice Address - Fax:973-334-7615
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2011-06-24
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NJMA55345207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E76015Medicare UPIN