Healthcare Provider Details

I. General information

NPI: 1790770279
Provider Name (Legal Business Name): MARCARIOUS A MARIYAMPILLAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 BLOOMFIELD AVE SUITE LL-1
VERONA NJ
07044-1366
US

IV. Provider business mailing address

825 BLOOMFIELD AVE SUITE LL-1
VERONA NJ
07044-1366
US

V. Phone/Fax

Practice location:
  • Phone: 973-239-3770
  • Fax: 973-239-3774
Mailing address:
  • Phone: 973-239-3770
  • Fax: 973-239-3774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06542600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: