Provider Demographics
NPI:1609422393
Name:SHOULARS, DARRELL PETER (MA, MA)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:PETER
Last Name:SHOULARS
Suffix:
Gender:M
Credentials:MA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N END TER
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-4404
Mailing Address - Country:US
Mailing Address - Phone:862-704-3524
Mailing Address - Fax:
Practice Address - Street 1:10 N END TER
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4404
Practice Address - Country:US
Practice Address - Phone:862-704-3524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ778909261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities