Healthcare Provider Details

I. General information

NPI: 1578902565
Provider Name (Legal Business Name): ROBERT HENRI WAUTERS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2013
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E NORTHFIELD RD
LIVINGSTON NJ
07039-4532
US

IV. Provider business mailing address

PO BOX 986513 DEPT 100
BOSTON MA
02298-6513
US

V. Phone/Fax

Practice location:
  • Phone: 973-436-1560
  • Fax:
Mailing address:
  • Phone: 910-219-8326
  • Fax: 910-939-4269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2022-00411
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number25MA11933500
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number0101256874
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: