Provider Demographics
NPI:1477784155
Name:KENDALL PARK MEDICAL GROUP
Entity type:Organization
Organization Name:KENDALL PARK MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:F
Authorized Official - Last Name:LARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-940-0505
Mailing Address - Street 1:3 STANWORTH RD # A
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824-1003
Mailing Address - Country:US
Mailing Address - Phone:732-940-0505
Mailing Address - Fax:732-940-1997
Practice Address - Street 1:3 STANWORTH RD # A
Practice Address - Street 2:
Practice Address - City:KENDALL PARK
Practice Address - State:NJ
Practice Address - Zip Code:08824-1003
Practice Address - Country:US
Practice Address - Phone:732-940-0505
Practice Address - Fax:732-940-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04235300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty