Healthcare Provider Details

I. General information

NPI: 1063961548
Provider Name (Legal Business Name): ELENA I SAFRONOVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ RM 307
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2328
  • Fax:
Mailing address:
  • Phone: 848-288-6935
  • Fax: 732-790-0107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA11744500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: