Provider Demographics
NPI:1679715346
Name:MANKOVETSKIY, MARINA (DPM)
Entity type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:MANKOVETSKIY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 OAKRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069
Mailing Address - Country:US
Mailing Address - Phone:917-817-9433
Mailing Address - Fax:
Practice Address - Street 1:290 MADISON AVE
Practice Address - Street 2:FL 6
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-6306
Practice Address - Country:US
Practice Address - Phone:917-817-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00300000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400016570Medicare PIN