Provider Demographics
NPI:1518088202
Name:WERTHEIM, MORDECAI (MD)
Entity Type:Individual
Prefix:
First Name:MORDECAI
Middle Name:
Last Name:WERTHEIM
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 1:1275 15TH ST
Mailing Address - Street 2:APT 17 E
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1950
Mailing Address - Country:US
Mailing Address - Phone:646-251-1112
Mailing Address - Fax:
Practice Address - Street 1:321 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1429
Practice Address - Country:US
Practice Address - Phone:646-251-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2012-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156339-1207R00000X
NJ25MA04466800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF21750Medicare UPIN