Provider Demographics
NPI:1790785921
Name:KAWEBLUM, MOISES (MD)
Entity Type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:KAWEBLUM
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 1:500 RIVER AVE
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4738
Mailing Address - Country:US
Mailing Address - Phone:732-905-4446
Mailing Address - Fax:732-961-7233
Practice Address - Street 1:500 RIVER AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4738
Practice Address - Country:US
Practice Address - Phone:732-905-4446
Practice Address - Fax:732-961-7233
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07181100207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1324383OtherBLUE SHIELD
PA68694 269HOtherGEISINGER
PA814886OtherFIRST PRIORITY
PA0018742630003Medicaid
H28350Medicare UPIN
PAH28350Medicare UPIN
PA0018742630003Medicaid