=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659391266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICENTE NL MISION, M.D. PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 CANDLEWOOD COMMONS
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 97731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-370-1900
-----------------------------------------------------
Fax | 732-901-0916
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 CANDLEWOOD COMMONS
-----------------------------------------------------
City | HOWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 97731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-370-1900
-----------------------------------------------------
Fax | 732-901-0916
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICENTE NEVARDO LOZADA MISION
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 732-370-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MA038662
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------