Healthcare Provider Details

I. General information

NPI: 1063523892
Provider Name (Legal Business Name): WILLIAM KOHLBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 IRON BRIDGE RD STE 5
FREEHOLD NJ
07728-5305
US

IV. Provider business mailing address

501 IRON BRIDGE RD STE 5
FREEHOLD NJ
07728-5305
US

V. Phone/Fax

Practice location:
  • Phone: 732-780-7603
  • Fax: 732-308-3323
Mailing address:
  • Phone: 732-780-7603
  • Fax: 732-308-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMA38764
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: