Provider Demographics
NPI:1306949508
Name:PEDIATRIC MEDICAL GROUP OF CENTRAL JERSEY
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL GROUP OF CENTRAL JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LIONEL
Authorized Official - Middle Name:DIAZ
Authorized Official - Last Name:FOZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-458-1177
Mailing Address - Street 1:525 JACK MARTIN BOULEVARD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724
Mailing Address - Country:US
Mailing Address - Phone:732-458-1177
Mailing Address - Fax:732-458-5942
Practice Address - Street 1:525 JACK MARTIN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724
Practice Address - Country:US
Practice Address - Phone:732-458-1177
Practice Address - Fax:732-458-5942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty