Healthcare Provider Details

I. General information

NPI: 1952415705
Provider Name (Legal Business Name): AVERY S KUFLIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E KENNEDY BLVD
LAKEWOOD NJ
08701-1345
US

IV. Provider business mailing address

150 E KENNEDY BLVD
LAKEWOOD NJ
08701-1345
US

V. Phone/Fax

Practice location:
  • Phone: 732-364-0515
  • Fax: 732-364-6006
Mailing address:
  • Phone: 732-364-0515
  • Fax: 732-364-6006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA06547100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number25MA06547100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number25MA06547100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: