Healthcare Provider Details

I. General information

NPI: 1487164752
Provider Name (Legal Business Name): UPTOWN OB/GYN PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 STOCKTON DR
TOMS RIVER NJ
08755-6433
US

IV. Provider business mailing address

PO BOX 3727
CEDAR HILL TX
75106-3727
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax:
Mailing address:
  • Phone: 972-217-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberM8289
License Number StateTX

VIII. Authorized Official

Name: LINDA ANN RODRIGUE
Title or Position: OWNER/SOLE MEMBER
Credential: MD
Phone: 972-217-5958