Provider Demographics
NPI:1134545429
Name:CANDLEWOOD PEDIATRICS
Entity type:Organization
Organization Name:CANDLEWOOD PEDIATRICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR/MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHKOLNAYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-280-3100
Mailing Address - Street 1:1540 HWY. 138
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719
Mailing Address - Country:US
Mailing Address - Phone:732-280-3100
Mailing Address - Fax:732-280-3103
Practice Address - Street 1:1540 HWY. 138
Practice Address - Street 2:SUITE 105
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719
Practice Address - Country:US
Practice Address - Phone:732-280-3100
Practice Address - Fax:732-280-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06638500208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1497729842OtherNPI