Healthcare Provider Details

I. General information

NPI: 1841425196
Provider Name (Legal Business Name): CHARLOTTE SIMONE NUSSBAUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 OLD MARLTON PIKE STE 203
MEDFORD NJ
08055-8772
US

IV. Provider business mailing address

103 OLD MARLTON PIKE STE 203
MEDFORD NJ
08055-8772
US

V. Phone/Fax

Practice location:
  • Phone: 609-969-4844
  • Fax: 609-969-4255
Mailing address:
  • Phone: 609-969-4844
  • Fax: 609-969-4255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number25MA09337600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: