Healthcare Provider Details

I. General information

NPI: 1013958875
Provider Name (Legal Business Name): MAVOLA TENCH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 DELSEA DR N
GLASSBORO NJ
08028-1444
US

IV. Provider business mailing address

1120 DELSEA DR N
GLASSBORO NJ
08028-1444
US

V. Phone/Fax

Practice location:
  • Phone: 856-582-0500
  • Fax: 856-582-0163
Mailing address:
  • Phone: 856-582-0500
  • Fax: 856-582-0163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA06318700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: