MEDICARE: STEPHANIE E MITSOS M.D.

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	207R00000X	Internal Medicine Physician	25MA06156500	NJ

General Provider Information

NPI Number	:	1861679516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE E MITSOS M.D.

Provider Business Mailing Address
First Line	:	55 N GILBERT ST
Second Line	:	SUITE 3201
City	:	TINTON FALLS
State	:	NJ
Zip	:	07701-4955
Country	:	US
Telephone Number	:	732-450-0961
Fax Number	:	732-536-0213

Provider Business Practice Location Address
First Line	:	55 N GILBERT ST
Second Line	:	SUITE 3201
City	:	TINTON FALLS
State	:	NJ
Zip	:	07701-4955
Country	:	US
Telephone Number	:	732-450-0961
Fax Number	:	732-536-0213

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

Provider Enumeration Date	:	01/24/2008
Last Update Date	:	09/22/2016

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