Healthcare Provider Details

I. General information

NPI: 1669695425
Provider Name (Legal Business Name): DENISE LYNN WUNDERLER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 02/09/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4251 US 9 STE B
FREEHOLD NJ
07728-8304
US

IV. Provider business mailing address

4251 US 9 STE B
FREEHOLD NJ
07728-8304
US

V. Phone/Fax

Practice location:
  • Phone: 732-683-1800
  • Fax:
Mailing address:
  • Phone: 732-683-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB10009200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: