Provider Demographics
NPI:1447307038
Name:CORTON, JUAN J (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:J
Last Name:CORTON
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 1:219 60TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2805
Mailing Address - Country:US
Mailing Address - Phone:201-869-7880
Mailing Address - Fax:201-758-1583
Practice Address - Street 1:219 60TH ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2805
Practice Address - Country:US
Practice Address - Phone:201-869-7880
Practice Address - Fax:201-758-1583
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03655400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1925903Medicaid
NJ0054141OtherGHI
NJC55687Medicare UPIN
NJ455207Medicare ID - Type Unspecified