Provider Demographics
NPI:1265952717
Name:LOMOTAN, MICHELLE FUENTES (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:FUENTES
Last Name:LOMOTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:JOY
Other - Last Name:FUENTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 MAY ST STE E
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3266
Mailing Address - Country:US
Mailing Address - Phone:732-661-2020
Mailing Address - Fax:
Practice Address - Street 1:225 MAY ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3266
Practice Address - Country:US
Practice Address - Phone:732-661-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA10872400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty