Healthcare Provider Details

I. General information

NPI: 1184630808
Provider Name (Legal Business Name): ANDREW E MULBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

3 COOPER PLZ
CAMDEN NJ
08103-1438
US

V. Phone/Fax

Practice location:
  • Phone: 856-751-9339
  • Fax:
Mailing address:
  • Phone: 856-751-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD039755E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberMD039755E
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD039755E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6039707
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier001436126
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: