Provider Demographics
NPI:1881677490
Name:VANDERWERKEN, SUZANNE W (MD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:W
Last Name:VANDERWERKEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 W RED BANK AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1694
Mailing Address - Country:US
Mailing Address - Phone:856-853-2055
Mailing Address - Fax:856-848-2879
Practice Address - Street 1:75 W RED BANK AVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1694
Practice Address - Country:US
Practice Address - Phone:856-853-2055
Practice Address - Fax:856-848-2879
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA52279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4977807Medicaid
E13118Medicare UPIN
NJ080059AWFMedicare PIN