Provider Demographics
NPI:1174318844
Name:CUSTODIO, EWDIN J
Entity type:Individual
Prefix:
First Name:EWDIN
Middle Name:J
Last Name:CUSTODIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-4040
Mailing Address - Country:US
Mailing Address - Phone:856-285-0841
Mailing Address - Fax:
Practice Address - Street 1:521 RICHARD DR
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-4040
Practice Address - Country:US
Practice Address - Phone:856-285-0841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR22177100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily