Healthcare Provider Details

I. General information

NPI: 1174318844
Provider Name (Legal Business Name): EDWIN J CUSTODIO APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 S WHITE HORSE PIKE
HAMMONTON NJ
08037-2018
US

IV. Provider business mailing address

521 RICHARD DR
MILLVILLE NJ
08332-4040
US

V. Phone/Fax

Practice location:
  • Phone: 609-567-0200
  • Fax: 609-567-1951
Mailing address:
  • Phone: 856-285-0841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15527500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: