1134320013 NPI number — VINCENT CAPALBO MD

Table of content: VINCENT CAPALBO MD (NPI 1134320013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134320013 NPI number — VINCENT CAPALBO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAPALBO
Provider First Name:
VINCENT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134320013
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3998 FAIR RIDGE DR
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-2907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-295-9360
Provider Business Mailing Address Fax Number:
703-766-9725

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07102-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-877-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  25MA08291200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0139521 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".