Basic Information
Provider Information | |||||||||
NPI: | 1710274766 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARRIS | ||||||||
FirstName: | MEHRUBA | ||||||||
MiddleName: | ANWAR | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 150 BERGEN ST | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071032496 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 150 BERGEN ST | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071032496 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9739724300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2011 | ||||||||
LastUpdateDate: | 04/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PT0002X | ME127900 | FL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology | 207PT0002X | 25MA10895100 | NJ | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Medical Toxicology |
ID Information
ID | Type | State | Issuer | Description | 000000000 | 01 |   | N/A | OTHER |