Healthcare Provider Details

I. General information

NPI: 1134545429
Provider Name (Legal Business Name): CANDLEWOOD PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 HWY. 138 SUITE 105
WALL NJ
07719
US

IV. Provider business mailing address

1540 HWY. 138 SUITE 105
WALL NJ
07719
US

V. Phone/Fax

Practice location:
  • Phone: 732-280-3100
  • Fax: 732-280-3103
Mailing address:
  • Phone: 732-280-3100
  • Fax: 732-280-3103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06638500
License Number StateNJ

VIII. Authorized Official

Name: TATYANA SHKOLNAYA
Title or Position: PROPRIETOR/MEDICAL DOCTOR
Credential: M.D.
Phone: 732-280-3100