Provider Demographics
NPI:1114228871
Name:MEDICAL LASER SKIN CARE CENTER OF NEW JERSEY LLC
Entity type:Organization
Organization Name:MEDICAL LASER SKIN CARE CENTER OF NEW JERSEY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:ZEIDWERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-254-6400
Mailing Address - Street 1:465 CRANBURY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-7600
Mailing Address - Country:US
Mailing Address - Phone:732-254-6400
Mailing Address - Fax:
Practice Address - Street 1:465 CRANBURY RD STE 203
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-7600
Practice Address - Country:US
Practice Address - Phone:732-254-6400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB056553002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG10167Medicare UPIN