Provider Demographics
NPI:1508833484
Name:LAUTENBERG, MITCHEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHEL
Middle Name:A
Last Name:LAUTENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 ROUTE 37 WEST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-8050
Mailing Address - Country:US
Mailing Address - Phone:732-244-4400
Mailing Address - Fax:732-505-2171
Practice Address - Street 1:601 ROUTE 37 WEST
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8050
Practice Address - Country:US
Practice Address - Phone:732-244-4400
Practice Address - Fax:732-505-2171
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO6965100207W00000X
NJ25MA06965100207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8283508Medicaid
NJ180039086OtherRAILROAD MEDICARE
NJ035578BBUMedicare PIN
NJ180039086OtherRAILROAD MEDICARE