Healthcare Provider Details

I. General information

NPI: 1710240213
Provider Name (Legal Business Name): JOANNE MARMOL-MARMOLEJOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W RED BANK AVE
WOODBURY NJ
08096-1694
US

IV. Provider business mailing address

75 W RED BANK AVE
WOODBURY NJ
08096-1694
US

V. Phone/Fax

Practice location:
  • Phone: 856-853-2055
  • Fax: 856-848-2879
Mailing address:
  • Phone: 856-853-2055
  • Fax: 856-848-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA10703700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: