Provider Demographics
NPI:1518612761
Name:MOORMAN, MARK C JR
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:MOORMAN
Suffix:JR
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 1:2030 N BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-9132
Mailing Address - Country:US
Mailing Address - Phone:856-702-2259
Mailing Address - Fax:856-702-2261
Practice Address - Street 1:2030 N BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-9132
Practice Address - Country:US
Practice Address - Phone:856-702-2259
Practice Address - Fax:856-702-2261
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver