Healthcare Provider Details

I. General information

NPI: 1528050382
Provider Name (Legal Business Name): MARIO L MAIESE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 EGG HARBOR RD STE 1
SEWELL NJ
08080-2371
US

IV. Provider business mailing address

539 EGG HARBOR RD #1 WASHINGTON MEDICAL ARTS BUILDING
SEWELL NJ
08080-2371
US

V. Phone/Fax

Practice location:
  • Phone: 856-589-0300
  • Fax: 856-589-1753
Mailing address:
  • Phone: 856-589-0300
  • Fax: 856-589-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMB24565
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: