Healthcare Provider Details

I. General information

NPI: 1942380779
Provider Name (Legal Business Name): SOULA G. KONIARIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 FRENCH STREET SUITE 2300
NEW BRUNSWICK NJ
08901
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 732-235-6230
  • Fax: 732-235-8766
Mailing address:
  • Phone: 732-212-0051
  • Fax: 732-212-0713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number25MA061138
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number25MA06113800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: