Healthcare Provider Details

I. General information

NPI: 1659331114
Provider Name (Legal Business Name): JANETTE M WAHBA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 RIDGE RD
LYNDHURST NJ
07071-2739
US

IV. Provider business mailing address

525 RIDGE RD
LYNDHURST NJ
07071-2739
US

V. Phone/Fax

Practice location:
  • Phone: 201-935-5512
  • Fax: 201-935-1914
Mailing address:
  • Phone: 201-935-5512
  • Fax: 201-935-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA03093400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: