Provider Demographics
NPI:1518043470
Name:TECSON, MARIAVIDA TUPAZ (MD)
Entity type:Individual
Prefix:
First Name:MARIAVIDA
Middle Name:TUPAZ
Last Name:TECSON
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 1:116 MILLBURN AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1919
Mailing Address - Country:US
Mailing Address - Phone:973-921-9321
Mailing Address - Fax:973-921-9323
Practice Address - Street 1:116 MILLBURN AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1919
Practice Address - Country:US
Practice Address - Phone:973-921-9321
Practice Address - Fax:973-921-9323
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0047031Medicaid
I07681Medicare UPIN
079963Medicare ID - Type Unspecified