Basic Information
Provider Information | |||||||||
NPI: | 1942202775 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CALDERON-BANZON | ||||||||
FirstName: | OLGA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 66 W GILBERT ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TINTON FALLS | ||||||||
State: | NJ | ||||||||
PostalCode: | 077014918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7212120060 | ||||||||
FaxNumber: | 7322120061 | ||||||||
Practice Location | |||||||||
Address1: | 300 CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | EAST ORANGE | ||||||||
State: | NJ | ||||||||
PostalCode: | 070182819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9736728400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2005 | ||||||||
LastUpdateDate: | 02/18/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MA02802200 | NJ | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 7735502 | 05 | NJ |   | MEDICAID | P00321137 | 01 | NJ | RAILROAD MEDICARE | OTHER |