Provider Demographics
NPI:1376948364
Name:MARIN, JOHN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MARIN
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 1:20 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2602
Mailing Address - Country:US
Mailing Address - Phone:862-237-1455
Mailing Address - Fax:
Practice Address - Street 1:36 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-4119
Practice Address - Country:US
Practice Address - Phone:973-759-6569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018032363A00000X
NJ25MP00350700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant