Healthcare Provider Details

I. General information

NPI: 1740249671
Provider Name (Legal Business Name): KATHLEEN M. CERKVENIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 CEDAR HILL AVE
WYCKOFF NJ
07481-2150
US

IV. Provider business mailing address

541 CEDAR HILL AVENUE
WYCKOFF NJ
07481-2150
US

V. Phone/Fax

Practice location:
  • Phone: 201-652-0300
  • Fax: 201-444-6209
Mailing address:
  • Phone: 201-445-4630
  • Fax: 201-444-6209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA042021
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: