Provider Demographics
NPI:1639216260
Name:DRISCOLL, MARILYN MOORE (RD)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:MOORE
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7-24 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410
Mailing Address - Country:US
Mailing Address - Phone:201-796-8336
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVENUE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112
Practice Address - Country:US
Practice Address - Phone:973-926-4607
Practice Address - Fax:973-926-6288
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ719760133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2339245OtherUNITED HEALTH CARE
NJ3478305OtherAETNA US HEALTH CARE
NJP2951221OtherOXFORD HEALTH PLAN
NJ053623Medicare ID - Type UnspecifiedMEDICARE