Basic Information
| Provider Information | |||||||||
| NPI: | 1659372910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUKALIAN | ||||||||
| FirstName: | GREGORY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550340 | ||||||||
| FaxNumber: | 8563550330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1113 HOSPITAL DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | WILLINGBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080461103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098355821 | ||||||||
| FaxNumber: | 6098355827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB06369000 | NJ | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7031904 | 05 | NJ | MEDICAID |