Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 25MA04771800 | NJ |
N | 208800000X | Urologist | MD064953L | PA |
NPI | 1033180724 |
---|---|
Provider Name | Dr. Jack Dwosh |
First Address | Mount Laurel, NJ 08054-1573 |
Second Address | Mt. Laurel, NJ 08054 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2006 |
Last Update Date | 23/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0055472 | AETNA (01) | |
0073781000 | AMERIHEALTH (01) | |
C58105 | (02) |