Healthcare Provider Details

I. General information

NPI: 1689961401
Provider Name (Legal Business Name): VENTNOR PEDIATRICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 VENTNOR AVE SUITE #14
VENTNOR CITY NJ
08406-2167
US

IV. Provider business mailing address

6601 VENTNOR AVE SUITE #14
VENTNOR CITY NJ
08406-2167
US

V. Phone/Fax

Practice location:
  • Phone: 609-487-6507
  • Fax: 609-487-6508
Mailing address:
  • Phone: 609-487-6507
  • Fax: 609-487-6508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06156800
License Number StateNJ

VIII. Authorized Official

Name: MRS. EMIOLA O ASEMOTA
Title or Position: OWNER/CEO
Credential: M.D.
Phone: 609-487-6507