Healthcare Provider Details

I. General information

NPI: 1164458451
Provider Name (Legal Business Name): JERRY D MABAGOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ROUTE 70 STE 1C
BRICK NJ
08723-4022
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD STE 220
RED BANK NJ
07701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 732-279-6537
  • Fax: 732-458-6356
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06682500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: