Provider Demographics
NPI:1720136153
Name:CRONIN, STEPHEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:CRONIN
Suffix:
Gender:M
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 MACDONALD DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3011
Mailing Address - Country:US
Mailing Address - Phone:973-278-1100
Mailing Address - Fax:
Practice Address - Street 1:625 BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1977
Practice Address - Country:US
Practice Address - Phone:973-278-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04499800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1169106Medicaid
NJC55072Medicare UPIN
NJ1169106Medicaid