Provider Demographics
NPI:1891935557
Name:PEMBERTON, COLIN A, (MD)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:A,
Last Name:PEMBERTON
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 1:2 DEVONSHIRE TER
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2708
Mailing Address - Country:US
Mailing Address - Phone:973-444-0983
Mailing Address - Fax:
Practice Address - Street 1:500 ORANGE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-2944
Practice Address - Country:US
Practice Address - Phone:973-842-8398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ025MA08530400207R00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0198323Medicaid
NJ217501Medicare PIN