Healthcare Provider Details

I. General information

NPI: 1396716767
Provider Name (Legal Business Name): EDNA RETIRACION LOPEZ-MASLAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 BELLEVILLE AVE STE 202
BLOOMFIELD NJ
07003-3589
US

IV. Provider business mailing address

LB# 7550 PO BOX 95000
PHILADELPHIA PA
19195-7550
US

V. Phone/Fax

Practice location:
  • Phone: 973-743-0202
  • Fax: 973-743-0777
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA0653880
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: