Healthcare Provider Details

I. General information

NPI: 1548546286
Provider Name (Legal Business Name): EDISON FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 GROVE AVE
EDISON NJ
08820-3212
US

IV. Provider business mailing address

616 GROVE AVE
EDISON NJ
08820-3212
US

V. Phone/Fax

Practice location:
  • Phone: 732-548-6303
  • Fax: 732-549-4676
Mailing address:
  • Phone: 732-548-6303
  • Fax: 732-549-4676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA45007
License Number StateNJ

VIII. Authorized Official

Name: DR. MARIA S FLORES DIEPPA
Title or Position: OWNER
Credential: MD
Phone: 732-548-6303