Provider Demographics
NPI:1316946676
Name:MANGUBAT, MURILLO V (MD,)
Entity type:Individual
Prefix:
First Name:MURILLO
Middle Name:V
Last Name:MANGUBAT
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 1:406 LIPPINCOTT DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4168
Mailing Address - Country:US
Mailing Address - Phone:856-985-6800
Mailing Address - Fax:856-985-3535
Practice Address - Street 1:17 W RED BANK AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1630
Practice Address - Country:US
Practice Address - Phone:856-856-0955
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA30134208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3707806Medicaid
NJ101488DKLMedicare ID - Type Unspecified
NJC53243Medicare UPIN