Healthcare Provider Details

I. General information

NPI: 1659347086
Provider Name (Legal Business Name): KENNETH TREADWELL JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2006
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1387 CLINTON AVE
IRVINGTON NJ
07111-1442
US

IV. Provider business mailing address

1387 CLINTON AVE
IRVINGTON NJ
07111-1442
US

V. Phone/Fax

Practice location:
  • Phone: 973-372-1441
  • Fax: 973-372-6019
Mailing address:
  • Phone: 973-372-1441
  • Fax: 973-372-6019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA03828700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: