MEDICARE: DR. CARMELITA MABANTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	052399	GA
2	2080N0001X	Neonatal-Perinatal Medicine Physician	25MA08961100	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801879598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARMELITA MABANTA M.D.

Provider Business Mailing Address
First Line	:	19 DAVIS AVE
Second Line	:
City	:	NEPTUNE
State	:	NJ
Zip	:	07753-4488
Country	:	US
Telephone Number	:	732-776-4524
Fax Number	:	732-776-4639

Provider Business Practice Location Address
First Line	:	19 DAVIS AVE
Second Line	:
City	:	NEPTUNE
State	:	NJ
Zip	:	07753-4488
Country	:	US
Telephone Number	:	732-776-4524
Fax Number	:	732-776-4639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	11/11/2019

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