Provider Demographics
NPI:1912930082
Name:MANKARIOS, FARAG AMIN (MD)
Entity Type:Individual
Prefix:
First Name:FARAG
Middle Name:AMIN
Last Name:MANKARIOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 ROUTE 34
Mailing Address - Street 2:SUITE 216
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-2519
Mailing Address - Country:US
Mailing Address - Phone:732-863-5515
Mailing Address - Fax:732-863-5516
Practice Address - Street 1:410 ROUTE 34
Practice Address - Street 2:SUITE 216
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-2519
Practice Address - Country:US
Practice Address - Phone:732-863-5515
Practice Address - Fax:732-863-5516
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07048000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8206708Medicaid
NJ037168Medicare PIN
NJH14158Medicare UPIN