Healthcare Provider Details

I. General information

NPI: 1770178840
Provider Name (Legal Business Name): GARDEN STATE MOBILE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 APPLE ST
TINTON FALLS NJ
07724-2636
US

IV. Provider business mailing address

67 APPLE ST
TINTON FALLS NJ
07724-2636
US

V. Phone/Fax

Practice location:
  • Phone: 732-314-7410
  • Fax: 732-351-2062
Mailing address:
  • Phone: 732-314-7410
  • Fax: 732-351-2062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ADIL MANZOOR
Title or Position: PHYSICIAN
Credential: DO
Phone: 732-314-7410