Provider Demographics
NPI:1528089414
Name:FULLENKAMP, MARK PATRICK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:PATRICK
Last Name:FULLENKAMP
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 1:66 W GILBERT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:1 ROBERT WOOD JOHNSON PL
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1928
Practice Address - Country:US
Practice Address - Phone:732-937-8841
Practice Address - Fax:732-418-8492
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08100300207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00412626OtherRR MCR PTAN
NJP00412626OtherRR MCR PTAN
116376DBHMedicare PIN
NJ116376302Medicare PIN
NJ116376CDYMedicare PIN
NJ116376AOLMedicare PIN