Provider Demographics
NPI:1629239884
Name:GEORGE, CYRIAC (DO)
Entity Type:Individual
Prefix:DR
First Name:CYRIAC
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 S BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:BLACKWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08012-2807
Mailing Address - Country:US
Mailing Address - Phone:856-228-1061
Mailing Address - Fax:856-228-1907
Practice Address - Street 1:535 S BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:BLACKWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08012
Practice Address - Country:US
Practice Address - Phone:856-228-1061
Practice Address - Fax:856-228-1907
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08413700208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356 SK3Medicare PIN