Healthcare Provider Details

I. General information

NPI: 1578491015
Provider Name (Legal Business Name): COSULICH DERMATOLOGY 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 HIGHWAY 138 BLDG 2
WALL TOWNSHIP NJ
07719-9693
US

IV. Provider business mailing address

3350 HIGHWAY 138 BLDG 2
WALL TOWNSHIP NJ
07719-9693
US

V. Phone/Fax

Practice location:
  • Phone: 732-280-1207
  • 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 Number
License Number State

VIII. Authorized Official

Name: SHIAOCHUNG SHEN
Title or Position: PRACTICE MANAGER
Credential:
Phone: 732-280-1200