Healthcare Provider Details

I. General information

NPI: 1811324304
Provider Name (Legal Business Name): SUMAN WASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 SUMMIT DR
BASKING RIDGE NJ
07920-1960
US

IV. Provider business mailing address

45 SUMMIT DR
BASKING RIDGE NJ
07920-1960
US

V. Phone/Fax

Practice location:
  • Phone: 609-480-9149
  • Fax:
Mailing address:
  • Phone: 609-480-9149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07450400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: