Healthcare Provider Details

I. General information

NPI: 1417157629
Provider Name (Legal Business Name): KINSHASA C MORTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 GEORGE ST 1ST FLOOR
NEW BRUNSWICK NJ
08901-2008
US

IV. Provider business mailing address

66 W GILBERT ST 2ND FLOOR
TINTON FALLS NJ
07701-4947
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-7828
  • Fax: 732-246-7317
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA08125600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MA08125600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: