Provider Demographics
NPI:1124169727
Name:WOODBRIDGE PEDIATRICS & ADOLESCENT CARE.,PC
Entity type:Organization
Organization Name:WOODBRIDGE PEDIATRICS & ADOLESCENT CARE.,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHARAIPOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-396-0813
Mailing Address - Street 1:80 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-1323
Mailing Address - Country:US
Mailing Address - Phone:732-396-4744
Mailing Address - Fax:732-396-9604
Practice Address - Street 1:80 LAKE AVE
Practice Address - Street 2:
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-1323
Practice Address - Country:US
Practice Address - Phone:732-396-4744
Practice Address - Fax:732-396-9604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04259400261QH0100X
NJ25MA05905800261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6560300Medicaid
NJ=========OtherTAX ID NUMBER