Provider Demographics
NPI:1164458451
Name:MABAGOS, JERRY D (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:MABAGOS
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 1:34 MACHESTER AVE, SUITE 201
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731
Mailing Address - Country:US
Mailing Address - Phone:609-242-5041
Mailing Address - Fax:609-489-4835
Practice Address - Street 1:34 MACHESTER AVE, SUITE 201
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1366
Practice Address - Country:US
Practice Address - Phone:609-242-5041
Practice Address - Fax:609-489-4835
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA66825208000000X
NJ25MA66825300207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8092800Medicaid
H08726Medicare UPIN
NJ8092800Medicaid