Provider Demographics
NPI:1295887339
Name:POBLETE, GWYN LAURICE (MD)
Entity type:Individual
Prefix:DR
First Name:GWYN
Middle Name:LAURICE
Last Name:POBLETE
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 1:39 WAGNER LN
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844-3328
Mailing Address - Country:US
Mailing Address - Phone:973-951-2718
Mailing Address - Fax:
Practice Address - Street 1:261 JAMES ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6392
Practice Address - Country:US
Practice Address - Phone:973-540-9393
Practice Address - Fax:973-540-1937
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08142100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics