Provider Demographics
NPI:1790785921
Name:KAWEBLUM, MOISES (MD)
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:KAWEBLUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LUCERNE DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2135
Mailing Address - Country:US
Mailing Address - Phone:732-722-7593
Mailing Address - Fax:888-965-2286
Practice Address - Street 1:1 LUCERNE DR
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-2135
Practice Address - Country:US
Practice Address - Phone:732-722-7593
Practice Address - Fax:732-722-7593
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07181100207LP2900X, 208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018742630003Medicaid
NJ0283118Medicaid
PA1324383OtherBLUE SHIELD
PA814886OtherFIRST PRIORITY
PA68694 269HOtherGEISINGER
PAH28350Medicare UPIN
PA0018742630003Medicaid