Provider Demographics
NPI:1326136417
Name:CHAVEZ, LAURA MONICA (DO)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MONICA
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22-18 BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:680 BROADWAY STE 5C
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1525
Practice Address - Country:US
Practice Address - Phone:973-523-3400
Practice Address - Fax:973-341-7438
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB072498207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8843601Medicaid