Basic Information
| Provider Information | |||||||||
| NPI: | 1194796953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEPASQUALE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5 FRANKLIN AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071093532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737597240 | ||||||||
| FaxNumber: | 9737597243 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 FRANKLIN AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071093532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737597240 | ||||||||
| FaxNumber: | 9737597243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA04575400 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0070823 | 05 | NJ | MEDICAID |