Provider Demographics
NPI:1831215896
Name:BLOOMFIELD PEDIATRICS,P.A.
Entity type:Organization
Organization Name:BLOOMFIELD PEDIATRICS,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDNA
Authorized Official - Middle Name:RETIRACION
Authorized Official - Last Name:LOPEZ-MASLAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-743-0202
Mailing Address - Street 1:329 BELLEVILLE AVENUE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5902
Mailing Address - Country:US
Mailing Address - Phone:973-743-0202
Mailing Address - Fax:973-743-0777
Practice Address - Street 1:329 BELLEVILLE AVENUE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5902
Practice Address - Country:US
Practice Address - Phone:973-743-0202
Practice Address - Fax:973-743-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0653882080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8148309Medicaid