Provider Demographics
NPI:1518115542
Name:GARDEN STATE PHYSICIANS P.C.
Entity Type:Organization
Organization Name:GARDEN STATE PHYSICIANS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEORA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-274-1274
Mailing Address - Street 1:10 JEFFERSON PLZ
Mailing Address - Street 2:STE. 100
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-9502
Mailing Address - Country:US
Mailing Address - Phone:732-274-1274
Mailing Address - Fax:732-355-0321
Practice Address - Street 1:10 JEFFERSON PLZ
Practice Address - Street 2:STE. 100
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-9542
Practice Address - Country:US
Practice Address - Phone:732-274-1274
Practice Address - Fax:732-355-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB068932207Q00000X
NJMA67505207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85891Medicare UPIN
H05108Medicare UPIN