Healthcare Provider Details

I. General information

NPI: 1619949252
Provider Name (Legal Business Name): MARIA THERESA MICALE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 HIGHWAY 35 STE 102
RED BANK NJ
07701-5919
US

IV. Provider business mailing address

401 ROUTE 73 N STE 320
MARLTON NJ
08053-3426
US

V. Phone/Fax

Practice location:
  • Phone: 732-530-5515
  • Fax: 732-530-5516
Mailing address:
  • Phone: 732-530-5515
  • Fax: 732-530-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB06865200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: