Healthcare Provider Details

I. General information

NPI: 1457303919
Provider Name (Legal Business Name): EDWINA VERNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 S HARRISON ST
EAST ORANGE NJ
07018-1704
US

IV. Provider business mailing address

PO BOX 3155
EAST ORANGE NJ
07019-3155
US

V. Phone/Fax

Practice location:
  • Phone: 973-414-1886
  • Fax: 973-674-6134
Mailing address:
  • Phone: 973-414-1886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA03802100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: