Healthcare Provider Details

I. General information

NPI: 1659373439
Provider Name (Legal Business Name): FREDERICK POTULSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 HWY 70 BLD 6A
MANASQUAN NJ
08736
US

IV. Provider business mailing address

2640 HWY 70 BLD 6A
MANASQUAN NJ
08736
US

V. Phone/Fax

Practice location:
  • Phone: 732-528-5900
  • Fax: 732-528-0887
Mailing address:
  • Phone: 732-528-5900
  • Fax: 732-528-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMA40445
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: