Healthcare Provider Details

I. General information

NPI: 1851601330
Provider Name (Legal Business Name): GARDEN STATE PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 AMBOY AVE.
EDISON NJ
08837
US

IV. Provider business mailing address

1002 AMBOY AVE.
EDISON NJ
08837
US

V. Phone/Fax

Practice location:
  • Phone: 732-274-1274
  • Fax: 732-355-0321
Mailing address:
  • Phone: 732-274-1274
  • Fax: 732-355-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB06893200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06750500
License Number StateNJ

VIII. Authorized Official

Name: DR. SONIA DEORA
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 732-274-1274