Healthcare Provider Details

I. General information

NPI: 1053042499
Provider Name (Legal Business Name): MARY BLANCHET CONKLIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PATERSON ST RM 2133
NEW BRUNSWICK NJ
08901-1962
US

IV. Provider business mailing address

125 PATERSON ST RM 2133
NEW BRUNSWICK NJ
08901-1962
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-6600
  • Fax:
Mailing address:
  • Phone: 732-235-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA13131000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: