Healthcare Provider Details

I. General information

NPI: 1528057866
Provider Name (Legal Business Name): COSTAS A KAIAFAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DIAMOND HILL RD SUMMIT MEDICAL GROUP
BERKELEY HEIGHTS NJ
07922-2104
US

IV. Provider business mailing address

1 DIAMOND HILL RD SUMMIT MEDICAL GROUP
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 908-273-4300
  • Fax: 908-790-6524
Mailing address:
  • Phone: 908-273-4300
  • Fax: 908-790-6524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMA68406
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA06840600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: