Provider Demographics
NPI:1457593196
Name:CORAL DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:CORAL DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MANJUSHREE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATADIAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:917-257-7227
Mailing Address - Street 1:PO BOX 3042
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0342
Mailing Address - Country:US
Mailing Address - Phone:973-779-7354
Mailing Address - Fax:973-779-7385
Practice Address - Street 1:684 MARKET ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07513-1231
Practice Address - Country:US
Practice Address - Phone:917-257-7227
Practice Address - Fax:973-807-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07597800207P00000X, 207R00000X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0044377Medicaid
NJ25MB07597800OtherSTATE LICENSE
NJ077191Medicare PIN
NJ25MB07597800OtherSTATE LICENSE