Provider Demographics
NPI:1881732162
Name:GENITOURINARY SURGEONS OF NEW JERSEY PA
Entity type:Organization
Organization Name:GENITOURINARY SURGEONS OF NEW JERSEY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOOTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-685-2138
Mailing Address - Street 1:212 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE MEAD
Mailing Address - State:NJ
Mailing Address - Zip Code:08502-4635
Mailing Address - Country:US
Mailing Address - Phone:908-431-0992
Mailing Address - Fax:
Practice Address - Street 1:211 COURTYARD DR
Practice Address - Street 2:
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844-4247
Practice Address - Country:US
Practice Address - Phone:908-685-2138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06560100173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJK0951438Medicare PIN
NJG53395Medicare UPIN