Provider Demographics
NPI:1528015153
Name:LAKEWOOD PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:LAKEWOOD PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-363-1424
Mailing Address - Street 1:101 PROSPECT ST
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5020
Mailing Address - Country:US
Mailing Address - Phone:732-363-1424
Mailing Address - Fax:732-370-0714
Practice Address - Street 1:101 PROSPECT ST
Practice Address - Street 2:SUITE 112
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5020
Practice Address - Country:US
Practice Address - Phone:732-363-1424
Practice Address - Fax:732-370-0714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02835000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1299301Medicaid