Provider Demographics
NPI:1811305444
Name:GARDEN STATE DERMATOLOGY LLC
Entity type:Organization
Organization Name:GARDEN STATE DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PREETHI
Authorized Official - Middle Name:V
Authorized Official - Last Name:RAMASWAMY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-314-6567
Mailing Address - Street 1:7 MALTESE DR
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5815
Mailing Address - Country:US
Mailing Address - Phone:617-314-6567
Mailing Address - Fax:
Practice Address - Street 1:201 NEW JERSEY 17
Practice Address - Street 2:FLOOR 11
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070
Practice Address - Country:US
Practice Address - Phone:617-314-6567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09032700261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty