Healthcare Provider Details

I. General information

NPI: 1326210485
Provider Name (Legal Business Name): IRENE MAMKIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2008
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 MOUNT PLEASANT AVE
WEST ORANGE NJ
07052-2724
US

IV. Provider business mailing address

375 MOUNT PLEASANT AVE
WEST ORANGE NJ
07052-2724
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-6900
  • Fax: 973-322-6999
Mailing address:
  • Phone: 973-322-6900
  • Fax: 973-322-6999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number250979
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number250979
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: