Provider Demographics
NPI:1053643361
Name:MAYORQUIN, BERTHA (MD)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:MAYORQUIN
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:PO BOX 1557
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-7157
Mailing Address - Country:US
Mailing Address - Phone:201-918-2239
Mailing Address - Fax:201-918-2243
Practice Address - Street 1:377 JERSEY AVE
Practice Address - Street 2:SUITE 470
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-0000
Practice Address - Country:US
Practice Address - Phone:201-918-2239
Practice Address - Fax:201-918-2243
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08638600207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine