Provider Demographics
NPI:1245339779
Name:SHADIACK, EDWARD CHARLES JR (DO)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:CHARLES
Last Name:SHADIACK
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 NE CENTRAL AVE # 02
Mailing Address - Street 2:
Mailing Address - City:SEASIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08752-1306
Mailing Address - Country:US
Mailing Address - Phone:732-830-4884
Mailing Address - Fax:
Practice Address - Street 1:1200 NE CENTRAL AVE # 02
Practice Address - Street 2:
Practice Address - City:SEASIDE PARK
Practice Address - State:NJ
Practice Address - Zip Code:08752-1306
Practice Address - Country:US
Practice Address - Phone:732-830-4884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB41240207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine