Provider Demographics
NPI:1306834502
Name:MAITIN, IAN B (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:B
Last Name:MAITIN
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-566-7010
Mailing Address - Fax:856-566-6956
Practice Address - Street 1:42 E LAUREL RD STE 1700
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-7010
Practice Address - Fax:856-566-6956
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05556000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014118890001Medicaid
F58164Medicare UPIN
746697DWKMedicare ID - Type Unspecified