MEDICARE: IRINI D MENTAKIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	MA 38786	NJ

General Provider Information

NPI Number	:	1699771246
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRINI D MENTAKIS MD

Provider Business Mailing Address
First Line	:	PO BOX 334
Second Line	:
City	:	WAYNE
State	:	NJ
Zip	:	07474-0334
Country	:	US
Telephone Number	:	201-804-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 BALDWIN AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07304-3154
Country	:	US
Telephone Number	:	201-714-7903
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/08/2007

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