Provider Demographics
NPI:1659350189
Name:KETELAAR, PIETER JAN (MD)
Entity Type:Individual
Prefix:
First Name:PIETER
Middle Name:JAN
Last Name:KETELAAR
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 1:1608 HIGHWAY 88
Mailing Address - Street 2:SUITE 208
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-3009
Mailing Address - Country:US
Mailing Address - Phone:732-458-7878
Mailing Address - Fax:732-840-6378
Practice Address - Street 1:1608 HIGHWAY 88
Practice Address - Street 2:SUITE 208
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3009
Practice Address - Country:US
Practice Address - Phone:732-458-7878
Practice Address - Fax:732-840-6378
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02713800207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1815601Medicaid
C63179Medicare UPIN
191030095Medicare ID - Type Unspecified