Provider Demographics
NPI:1578504205
Name:BORJA, MANUEL LOPEZ (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:LOPEZ
Last Name:BORJA
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 1:59 TRAUTWEIN CRES
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2935
Mailing Address - Country:US
Mailing Address - Phone:201-768-4806
Mailing Address - Fax:201-963-0011
Practice Address - Street 1:201 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1112
Practice Address - Country:US
Practice Address - Phone:201-792-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA41473207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3943607Medicaid
NJD19297Medicare UPIN
NJ3943607Medicaid