=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851601330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDEN STATE PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2010
-----------------------------------------------------
Last Update Date | 04/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 AMBOY AVE.
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-274-1274
-----------------------------------------------------
Fax | 732-355-0321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1002 AMBOY AVE.
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-274-1274
-----------------------------------------------------
Fax | 732-355-0321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. SONIA DEORA
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 732-274-1274
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB06893200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA06750500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------