Healthcare Provider Details

I. General information

NPI: 1720021827
Provider Name (Legal Business Name): RITA RIAWATI GUNAWAN M.D., F.A.A.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 EASTON AVE
SOMERSET NJ
08873-1818
US

IV. Provider business mailing address

650 EASTON AVE
SOMERSET NJ
08873-1818
US

V. Phone/Fax

Practice location:
  • Phone: 732-545-6464
  • Fax: 732-545-9690
Mailing address:
  • Phone: 732-545-6464
  • Fax: 732-545-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMA53298
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: