Provider Demographics
NPI:1659340255
Name:FAHSBENDER, MARY MAGNUSEN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MAGNUSEN
Last Name:FAHSBENDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:MAGNUSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5678 BERKSHIRE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07438-9370
Mailing Address - Country:US
Mailing Address - Phone:973-697-0200
Mailing Address - Fax:973-383-0448
Practice Address - Street 1:5678 BERKSHIRE VALLEY RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07438-9370
Practice Address - Country:US
Practice Address - Phone:973-697-0200
Practice Address - Fax:973-383-0448
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB56521207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4583400Medicaid
NJ672302DSVMedicare ID - Type Unspecified
NJ4583400Medicaid