Healthcare Provider Details

I. General information

NPI: 1730442443
Provider Name (Legal Business Name): MARK NASHAAT GHOBRIAL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W SAINT GEORGES AVE FL 2
LINDEN NJ
07036-3900
US

IV. Provider business mailing address

210 W SAINT GEORGES AVE FL 2
LINDEN NJ
07036-3900
US

V. Phone/Fax

Practice location:
  • Phone: 908-486-1111
  • Fax: 908-486-2723
Mailing address:
  • Phone: 908-486-1111
  • Fax: 908-486-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberH83566
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number25MB10332000
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MB10332000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: