Provider Demographics
NPI:1942226154
Name:KASTNER, THEODORE ANDREW (MD,MS)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:ANDREW
Last Name:KASTNER
Suffix:
Gender:M
Credentials:MD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3045
Mailing Address - Country:US
Mailing Address - Phone:973-338-4200
Mailing Address - Fax:
Practice Address - Street 1:1285 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3045
Practice Address - Country:US
Practice Address - Phone:973-338-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA47761103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1212907Medicaid
NJ1212907Medicaid
NJ55127Medicare UPIN