Provider Demographics
NPI:1013209626
Name:FAKTOR, MITCHELL JOSEF
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JOSEF
Last Name:FAKTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MITCHELL
Other - Middle Name:JOSEF
Other - Last Name:FAKTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:2528 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-2130
Mailing Address - Country:US
Mailing Address - Phone:732-223-7444
Mailing Address - Fax:732-223-7444
Practice Address - Street 1:2528 RIVER RD
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-2130
Practice Address - Country:US
Practice Address - Phone:732-223-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-15
Last Update Date:2011-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06119300207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery