Healthcare Provider Details

I. General information

NPI: 1124282330
Provider Name (Legal Business Name): ETHEL AND RAPHAEL PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 HIGHWAY 35 SUITE 104
OCEAN NJ
07712-3532
US

IV. Provider business mailing address

1405 HIGHWAY 35 SUITE 104
OCEAN NJ
07712-3532
US

V. Phone/Fax

Practice location:
  • Phone: 732-531-2200
  • Fax: 732-531-2900
Mailing address:
  • Phone: 732-531-2200
  • Fax: 732-531-2900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07961200
License Number StateNJ

VIII. Authorized Official

Name: OLUKEMI OMOTOSO
Title or Position: OWNER
Credential: MD
Phone: 732-531-2200