Healthcare Provider Details

I. General information

NPI: 1316946676
Provider Name (Legal Business Name): MURILLO V MANGUBAT M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 W RED BANK AVE SUITE 303
WOODBURY NJ
08096-1630
US

IV. Provider business mailing address

406 LIPPINCOTT DR SUITE F
MARLTON NJ
08053-4168
US

V. Phone/Fax

Practice location:
  • Phone: 856-856-0955
  • Fax:
Mailing address:
  • Phone: 856-985-6800
  • Fax: 856-985-3535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMA30134
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: