Provider Demographics
NPI:1730130840
Name:MABANTA, RICARDO Y (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:Y
Last Name:MABANTA
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1001 ROUTE 73 N UPPR LEVEL A & MAIN LEVEL
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4524
Practice Address - Country:US
Practice Address - Phone:856-988-4444
Practice Address - Fax:856-988-0553
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0595972084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6525105Medicaid
F46135Medicare UPIN
NJ747579AT5Medicare ID - Type Unspecified