Provider Demographics
NPI:1558738898
Name:MOMAH, TIMOTHY (MT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MOMAH
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 W LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:RAHWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07065-2537
Mailing Address - Country:US
Mailing Address - Phone:848-467-9311
Mailing Address - Fax:
Practice Address - Street 1:536 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-2537
Practice Address - Country:US
Practice Address - Phone:848-467-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015075-1246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist