Healthcare Provider Details

I. General information

NPI: 1043507270
Provider Name (Legal Business Name): MEJIA PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 N BROAD ST
ELIZABETH NJ
07208-3300
US

IV. Provider business mailing address

433 N BROAD ST
ELIZABETH NJ
07208-3300
US

V. Phone/Fax

Practice location:
  • Phone: 908-436-1002
  • Fax: 908-436-1109
Mailing address:
  • Phone: 908-436-1002
  • Fax: 908-436-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number1428465
License Number StateNJ

VIII. Authorized Official

Name: JOHANNA J GONZALEZ MEJIA
Title or Position: OWNER
Credential:
Phone: 908-436-1002