Healthcare Provider Details

I. General information

NPI: 1124361878
Provider Name (Legal Business Name): TINA DHEBARIA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1945 ROUTE 33
NEPTUNE NJ
07753
US

IV. Provider business mailing address

1945 CORLIES AVENUE
NEPTUNE NJ
07753-4858
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-4220
  • Fax:
Mailing address:
  • Phone: 732-776-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number25MB09911500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: