Provider Demographics
NPI:1316055973
Name:MIRCEA, CORNEL (MD)
Entity type:Individual
Prefix:DR
First Name:CORNEL
Middle Name:
Last Name:MIRCEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HIGHLAND AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-1527
Mailing Address - Country:US
Mailing Address - Phone:973-680-5522
Mailing Address - Fax:
Practice Address - Street 1:123 HIGHLAND AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-1527
Practice Address - Country:US
Practice Address - Phone:973-689-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA065118174400000X
NJ25MA06511800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7458100Medicaid
NJ223617798OtherEIN
NJ7458100Medicaid