Provider Demographics
NPI:1083683924
Name:MARTIN-YEBOAH, PATRICK VAN (MD)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:VAN
Last Name:MARTIN-YEBOAH
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:PO BOX 3155
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07019-3155
Mailing Address - Country:US
Mailing Address - Phone:973-944-1089
Mailing Address - Fax:973-866-0023
Practice Address - Street 1:185 CENTRAL AVE
Practice Address - Street 2:SUITE 601
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-3332
Practice Address - Country:US
Practice Address - Phone:973-944-1089
Practice Address - Fax:973-866-0023
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA061936208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6529402Medicaid
NJG41956Medicare UPIN