Provider Demographics
NPI:1851603120
Name:CONDOLUCI, MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:CONDOLUCI
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:709 HADDONFIELD BERLIN RD
Mailing Address - Street 2:GARDEN STATE INFECTIOUS DISEASES ASSOCIATES, P.A.
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-3715
Mailing Address - Country:US
Mailing Address - Phone:856-566-3190
Mailing Address - Fax:856-783-2193
Practice Address - Street 1:709 HADDONFIELD BERLIN RD
Practice Address - Street 2:GARDEN STATE INFECTIOUS DISEASES ASSOCIATES, P.A.
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-3715
Practice Address - Country:US
Practice Address - Phone:856-566-3190
Practice Address - Fax:856-783-2193
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2017-02-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MB09385700207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0476137Medicaid
NJ407128ZGH1Medicare PIN