Provider Demographics
NPI:1659372910
Name:MUKALIAN, GREGORY (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:MUKALIAN
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1113 HOSPITAL DR
Practice Address - Street 2:SUITE 304
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1103
Practice Address - Country:US
Practice Address - Phone:609-835-5821
Practice Address - Fax:609-835-5827
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06369000208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7031904Medicaid
NJ7031904Medicaid
NJ193712Medicare PIN