Healthcare Provider Details

I. General information

NPI: 1417282922
Provider Name (Legal Business Name): J CALVIN CHATLOS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MAIN ST
FREEHOLD NJ
07728-2529
US

IV. Provider business mailing address

400 W MAIN ST
FREEHOLD NJ
07728-2529
US

V. Phone/Fax

Practice location:
  • Phone: 732-414-6001
  • Fax: 732-677-3149
Mailing address:
  • Phone: 732-414-6001
  • Fax: 732-677-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberMA 46262
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMA 46262
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMA 46262
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMA 46262
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN CALVIN CHATLOS JR.
Title or Position: SOLE PROPRIETOR
Credential: MD
Phone: 732-414-6001