Healthcare Provider Details

I. General information

NPI: 1063496149
Provider Name (Legal Business Name): MAMTA FULORIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 POLLARD RD
MOUNTAIN LAKES NJ
07046-1652
US

IV. Provider business mailing address

100 POLLARD RD
MOUNTAIN LAKES NJ
07046-1652
US

V. Phone/Fax

Practice location:
  • Phone: 732-318-8753
  • Fax:
Mailing address:
  • Phone: 732-318-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number9801647
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number103790
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: