Provider Demographics
NPI:1003819905
Name:MORI, MAYUMI A (MD)
Entity Type:Individual
Prefix:
First Name:MAYUMI
Middle Name:A
Last Name:MORI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 15TH ST
Mailing Address - Street 2:APT 11G
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1958
Mailing Address - Country:US
Mailing Address - Phone:973-326-8895
Mailing Address - Fax:973-326-6805
Practice Address - Street 1:218 RIDGEDALE AVE
Practice Address - Street 2:
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-2109
Practice Address - Country:US
Practice Address - Phone:973-326-8895
Practice Address - Fax:973-326-6805
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA64405174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7000901Medicaid
890516BC8Medicare ID - Type Unspecified
G33013Medicare UPIN