Provider Demographics
NPI:1770540890
Name:PRINCETON DERMATOLOGY ASSOCIATES KENDALL PARKPC
Entity type:Organization
Organization Name:PRINCETON DERMATOLOGY ASSOCIATES KENDALL PARKPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KAUFMANN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:609-683-4999
Mailing Address - Street 1:301 N HARRISON ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-3512
Mailing Address - Country:US
Mailing Address - Phone:609-683-4999
Mailing Address - Fax:609-683-0298
Practice Address - Street 1:1543 STATE HIGHWAY 27
Practice Address - Street 2:SUITE31
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-3904
Practice Address - Country:US
Practice Address - Phone:732-297-8866
Practice Address - Fax:732-821-0626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCJ5645OtherRAILROAD MEDICARE
NJ0099064000OtherAMERIHEALTH
=========OtherCOMMERCIAL INSURANCES
NJ050195Medicare ID - Type Unspecified