Healthcare Provider Details

I. General information

NPI: 1154499168
Provider Name (Legal Business Name): MICHAEL K MANTINAOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CATAMARAN COURT
MOUNT ARLINGTON NJ
07856
US

IV. Provider business mailing address

24 CATAMARAN COURT
MOUNT ARLINGTON NJ
07856
US

V. Phone/Fax

Practice location:
  • Phone: 973-770-1685
  • Fax:
Mailing address:
  • Phone: 973-770-1685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMA073187
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: