Provider Demographics
NPI:1790770279
Name:MARIYAMPILLAI, MARCARIOUS A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCARIOUS
Middle Name:A
Last Name:MARIYAMPILLAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE LL-1
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1366
Mailing Address - Country:US
Mailing Address - Phone:973-239-3770
Mailing Address - Fax:973-239-3774
Practice Address - Street 1:825 BLOOMFIELD AVE
Practice Address - Street 2:SUITE LL-1
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1366
Practice Address - Country:US
Practice Address - Phone:973-239-3770
Practice Address - Fax:973-239-3774
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06542600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7326904Medicaid
NJG55835Medicare UPIN
NJ959141PLHMedicare ID - Type Unspecified