Provider Demographics
NPI:1073947321
Name:MAMPILLY, AJAY S
Entity Type:Individual
Prefix:
First Name:AJAY
Middle Name:S
Last Name:MAMPILLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 ROLLINSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4625
Mailing Address - Country:US
Mailing Address - Phone:973-517-2094
Mailing Address - Fax:
Practice Address - Street 1:100 KINDERKAMACK RD
Practice Address - Street 2:
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1828
Practice Address - Country:US
Practice Address - Phone:888-493-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00300600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant