Healthcare Provider Details

I. General information

NPI: 1033740774
Provider Name (Legal Business Name): MONMOUTH VASCULAR IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1198 LAKEWOOD RD
TOMS RIVER NJ
08753-2237
US

IV. Provider business mailing address

4 MOUNTAIN LN
HOLMDEL NJ
07733-1107
US

V. Phone/Fax

Practice location:
  • Phone: 732-201-2225
  • Fax: 888-960-2493
Mailing address:
  • Phone: 732-201-2225
  • Fax: 888-960-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LEV PUKIN
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 732-201-2225