Provider Demographics
NPI:1184792814
Name:ETHERIDGE, BARBARA ANNE (MD)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:ANNE
Last Name:ETHERIDGE
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 1:27 CLYDE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5039
Mailing Address - Country:US
Mailing Address - Phone:732-246-0057
Mailing Address - Fax:732-745-7070
Practice Address - Street 1:27 CLYDE RD STE 102
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5039
Practice Address - Country:US
Practice Address - Phone:732-246-0057
Practice Address - Fax:732-745-7070
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06795700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7743408Medicaid
NJG80498Medicare UPIN
NJ019169Medicare ID - Type Unspecified