Healthcare Provider Details

I. General information

NPI: 1821550948
Provider Name (Legal Business Name): NITIN POTHEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 ROUTE 88 FL 3
BRICK NJ
08724-3018
US

IV. Provider business mailing address

1610 ROUTE 88 FL 3
BRICK NJ
08724-3018
US

V. Phone/Fax

Practice location:
  • Phone: 732-295-6543
  • Fax:
Mailing address:
  • Phone: 732-295-6549
  • Fax: 732-791-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA11631700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: