Provider Demographics
NPI:1528098068
Name:CONDON, MARJORIE MARIE (DO)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:MARIE
Last Name:CONDON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450
Mailing Address - Country:US
Mailing Address - Phone:201-689-1933
Mailing Address - Fax:201-689-1935
Practice Address - Street 1:106 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450
Practice Address - Country:US
Practice Address - Phone:201-689-1933
Practice Address - Fax:201-689-1935
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB54119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7177003Medicaid
NJ7177003Medicaid
E84478Medicare UPIN