Provider Demographics
NPI:1063496149
Name:FULORIA, MAMTA (MD)
Entity type:Individual
Prefix:DR
First Name:MAMTA
Middle Name:
Last Name:FULORIA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POLLARD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1652
Mailing Address - Country:US
Mailing Address - Phone:732-318-8753
Mailing Address - Fax:
Practice Address - Street 1:100 POLLARD RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1652
Practice Address - Country:US
Practice Address - Phone:732-318-8753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98016472080N0001X
GA1037902080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H12940Medicare UPIN