Provider Demographics
NPI:1598795577
Name:AGRES, MILDRED (MD)
Entity Type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:
Last Name:AGRES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROUTE 59
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4927
Mailing Address - Country:US
Mailing Address - Phone:845-357-5775
Mailing Address - Fax:845-357-5777
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-779-7361
Practice Address - Fax:973-779-7385
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03956800207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4703502Medicaid
NJE53440Medicare UPIN
NJ4703502Medicaid