Provider Demographics
NPI:1245724145
Name:CALDERON, JUAN LUIS (STL, LMT)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:LUIS
Last Name:CALDERON
Suffix:
Gender:M
Credentials:STL, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 443
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-0443
Mailing Address - Country:US
Mailing Address - Phone:201-401-4204
Mailing Address - Fax:
Practice Address - Street 1:6002 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1420
Practice Address - Country:US
Practice Address - Phone:201-401-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01274200374K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner