Healthcare Provider Details

I. General information

NPI: 1427333632
Provider Name (Legal Business Name): COSULICH DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 HIGHWAY 138 BUILDING 2 SUITE 122
WALL TOWNSHIP NJ
07719-9693
US

IV. Provider business mailing address

3350 HIGHWAY 138 BUILDING 2 SUITE 122
WALL TOWNSHIP NJ
07719-9693
US

V. Phone/Fax

Practice location:
  • Phone: 732-280-1200
  • Fax: 732-280-1207
Mailing address:
  • Phone: 732-280-1200
  • Fax: 732-280-1207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number25MA04679500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number25MA04679500
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHAEL COSULICH
Title or Position: OWNER
Credential: M.D.
Phone: 732-280-1200