Basic Information
| Provider Information | |||||||||
| NPI: | 1033164553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHOENFELD | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 ROUTE 66 | ||||||||
| Address2: | SUITE 131 | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077537300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323834173 | ||||||||
| FaxNumber: | 7327411895 | ||||||||
| Practice Location | |||||||||
| Address1: | 741 NORTHFIELD AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | WEST ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070521174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732439729 | ||||||||
| FaxNumber: | 9732439674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 25MA04058200 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 711608 | 05 | NJ | MEDICAID |