Provider Demographics
NPI:1265415855
Name:MCCOY, MARY ELLEN M (DPM)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:M
Last Name:MCCOY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BEY LEA RD
Mailing Address - Street 2:STE 1
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2978
Mailing Address - Country:US
Mailing Address - Phone:732-505-9728
Mailing Address - Fax:732-505-9787
Practice Address - Street 1:61 LACEY RD
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-4439
Practice Address - Country:US
Practice Address - Phone:732-350-2424
Practice Address - Fax:732-350-2444
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00174700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0774901Medicaid
NJ0774901Medicaid
T45048Medicare UPIN