Provider Demographics
NPI:1275519738
Name:MIZRACHY, MARC LEONARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:LEONARD
Last Name:MIZRACHY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 ROUTE 206
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NJ
Mailing Address - Zip Code:08844
Mailing Address - Country:US
Mailing Address - Phone:908-431-5901
Mailing Address - Fax:908-431-5906
Practice Address - Street 1:719 ROUTE 206
Practice Address - Street 2:SUITE 107
Practice Address - City:HILLSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08844
Practice Address - Country:US
Practice Address - Phone:908-431-5901
Practice Address - Fax:908-431-5906
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD02538213EP1101X, 213ES0131X
NJ25MDO0253800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7369601Medicaid
026949Medicare PIN
NJ026949XAWMedicare PIN
NJ7369601Medicaid
NJ0980130001Medicare NSC
U75028Medicare UPIN