Healthcare Provider Details

I. General information

NPI: 1245590231
Provider Name (Legal Business Name): MICHAEL GENEREUX D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 WALNUT AVE
CLARK NJ
07066-1640
US

IV. Provider business mailing address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 732-388-7300
  • Fax: 732-388-1330
Mailing address:
  • Phone: 908-273-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB11790400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number279433
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: