Provider Demographics
NPI:1689969396
Name:C AND M KINTIROGLOU MD'S PA
Entity Type:Organization
Organization Name:C AND M KINTIROGLOU MD'S PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRIGETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-243-0002
Mailing Address - Street 1:1500 PLEASANT VALLEY WAY
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 PLEASANT VALLEY WAY
Practice Address - Street 2:SUITE 301
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2956
Practice Address - Country:US
Practice Address - Phone:973-243-0002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA031240002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty