Healthcare Provider Details

I. General information

NPI: 1801804034
Provider Name (Legal Business Name): MARINA M KOVTUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD
LYONS NJ
07939-5001
US

IV. Provider business mailing address

425 PARK AVE
BERKELEY HEIGHTS NJ
07922-1837
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax: 908-607-6367
Mailing address:
  • Phone: 908-286-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA70881
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: