Provider Demographics
NPI:1558418061
Name:POTIAN, MARCELINO M (MD)
Entity Type:Individual
Prefix:
First Name:MARCELINO
Middle Name:M
Last Name:POTIAN
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 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:LEVEL E
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-5787
Practice Address - Fax:973-972-4172
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03895200207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0840700Medicaid
NJD99034Medicare UPIN
NJ0840700Medicaid