Healthcare Provider Details

I. General information

NPI: 1497917868
Provider Name (Legal Business Name): KRISTYN PHELPS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

IV. Provider business mailing address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax:
Mailing address:
  • Phone: 732-363-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08422600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: