Provider Demographics
NPI:1013284108
Name:EAR NOSE AND THROAT SOLUTIONS OF NJ
Entity Type:Organization
Organization Name:EAR NOSE AND THROAT SOLUTIONS OF NJ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:I
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-235-0095
Mailing Address - Street 1:187 WASHINGTON AVE
Mailing Address - Street 2:SUITE 2I
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3935
Mailing Address - Country:US
Mailing Address - Phone:973-235-0090
Mailing Address - Fax:973-995-1145
Practice Address - Street 1:187 WASHINGTON AVE
Practice Address - Street 2:SUITE 2I
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3935
Practice Address - Country:US
Practice Address - Phone:973-235-0090
Practice Address - Fax:973-995-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-17
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA08175200207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty