Healthcare Provider Details

I. General information

NPI: 1205367539
Provider Name (Legal Business Name): EVAN MICHAEL WILEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 ROUTE 33,
NEPTUNE NJ
07753
US

IV. Provider business mailing address

331 NEWMAN SPRINGS ROAD BLDG. 2, SUITE 220
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-2342
  • Fax: 732-776-2344
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA169840
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number332507
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA13047400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: