Provider Demographics
NPI:1467725978
Name:DR MAYORQUIN CORPORATION
Entity Type:Organization
Organization Name:DR MAYORQUIN CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYORQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:551-697-3696
Mailing Address - Street 1:PO BOX 3550
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07303-3550
Mailing Address - Country:US
Mailing Address - Phone:201-918-2239
Mailing Address - Fax:201-918-2243
Practice Address - Street 1:377 JERSEY AVE
Practice Address - Street 2:SUITE 470
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4393
Practice Address - Country:US
Practice Address - Phone:201-918-2239
Practice Address - Fax:201-918-2243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08638600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty