Provider Demographics
NPI:1366411084
Name:MAMMEN-PRASAD, ELIZABETH K (MD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:K
Last Name:MAMMEN-PRASAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 UNION AVE
Mailing Address - Street 2:SUITE#603
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3262
Mailing Address - Country:US
Mailing Address - Phone:973-399-9250
Mailing Address - Fax:732-252-6634
Practice Address - Street 1:50 UNION AVE
Practice Address - Street 2:SUITE# 603
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3262
Practice Address - Country:US
Practice Address - Phone:973-399-9250
Practice Address - Fax:732-252-6634
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA054742002080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF36367Medicare UPIN