Provider Demographics
NPI:1851601330
Name:GARDEN STATE PHYSICIANS
Entity Type:Organization
Organization Name:GARDEN STATE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEORA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-274-1274
Mailing Address - Street 1:1002 AMBOY AVE.
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837
Mailing Address - Country:US
Mailing Address - Phone:732-274-1274
Mailing Address - Fax:732-355-0321
Practice Address - Street 1:1002 AMBOY AVE.
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837
Practice Address - Country:US
Practice Address - Phone:732-274-1274
Practice Address - Fax:732-355-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06893200207Q00000X
NJ25MA06750500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0189057Medicaid