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General NPI Number Information
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NPI Number | 1114228871
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Entity Type | Organization
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Legal Business Name | MEDICAL LASER SKIN CARE CENTER OF NEW JERSEY LLC
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Dates
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Enumeration Date | 11/12/2010
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Last Update Date | 11/18/2010
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Provider Practice Location Address
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Address Line | 465 CRANBURY RD STE 203
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-7600
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Country | US
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Telephone | 732-254-6400
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Fax |
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Provider Business Mailing Address
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Address Line | 465 CRANBURY RD STE 203
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City | EAST BRUNSWICK
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State | NJ
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Zip | 08816-7600
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Country | US
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Telephone | 732-254-6400
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER/PRESIDENT
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Name | DR. DAVID M. ZEIDWERG
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Credential | D.O.
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Telephone | 732-254-6400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 25MB05655300
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License Number State | NJ
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