Provider Demographics
NPI:1891886214
Name:DIAZ-PUPEK, MARTA S (DO)
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:S
Last Name:DIAZ-PUPEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MULLICA HILL RD
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1702
Mailing Address - Country:US
Mailing Address - Phone:856-256-4333
Mailing Address - Fax:856-256-5642
Practice Address - Street 1:201 MULLICA HILL RD
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-1702
Practice Address - Country:US
Practice Address - Phone:856-256-4333
Practice Address - Fax:856-256-5642
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC200045672080P0204X
NJ25MB10292600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6611303Medicaid
VA6709281Medicaid
NY01720552Medicaid
MD3312003Medicaid
PA001532946Medicaid
MD3312003Medicaid
001819T34Medicare PIN