Healthcare Provider Details

I. General information

NPI: 1831215896
Provider Name (Legal Business Name): BLOOMFIELD PEDIATRICS,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 BELLEVILLE AVENUE 2ND FLOOR
BLOOMFIELD NJ
07003-5902
US

IV. Provider business mailing address

329 BELLEVILLE AVENUE 2ND FLOOR
BLOOMFIELD NJ
07003-5902
US

V. Phone/Fax

Practice location:
  • Phone: 973-743-0202
  • Fax: 973-743-0777
Mailing address:
  • Phone: 973-743-0202
  • Fax: 973-743-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMA065388
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier8148309
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. EDNA RETIRACION LOPEZ-MASLAK
Title or Position: OWNER
Credential: M.D.
Phone: 973-743-0202