Healthcare Provider Details

I. General information

NPI: 1497729842
Provider Name (Legal Business Name): TATYANA SHKOLNAYA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 HIGHWAY 138 SUITE 105
WALL NJ
07719-3763
US

IV. Provider business mailing address

1540 HWY 138 BLDG. 1, SUITE 105
WALL NJ
07719-3763
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:
Title or Position:
Credential:
Phone: