Provider Demographics
NPI:1881670321
Name:WASSER, KENNETH B (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:WASSER
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 1:43 N GILBERT ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4913
Mailing Address - Country:US
Mailing Address - Phone:732-530-7999
Mailing Address - Fax:732-530-7998
Practice Address - Street 1:43 N GILBERT ST STE 7
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4914
Practice Address - Country:US
Practice Address - Phone:732-530-7999
Practice Address - Fax:888-972-9904
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03998000207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1251104Medicaid
NJ1251104Medicaid
NJ110003471Medicare PIN
NJC54458Medicare UPIN