Provider Demographics
NPI:1255428124
Name:MALABANAN, NERISSA (MD)
Entity type:Individual
Prefix:
First Name:NERISSA
Middle Name:
Last Name:MALABANAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3196 KENNEDY BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2436
Mailing Address - Country:US
Mailing Address - Phone:201-319-9800
Mailing Address - Fax:201-437-9661
Practice Address - Street 1:1222 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-9211
Practice Address - Country:US
Practice Address - Phone:201-319-9800
Practice Address - Fax:201-437-9661
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06095100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7015704Medicaid
NJMA881897Medicare ID - Type Unspecified
NJG39191Medicare UPIN