1487632170 NPI number — VINCENT DISABELLA DO

Table of content: VINCENT DISABELLA DO (NPI 1487632170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487632170 NPI number — VINCENT DISABELLA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DISABELLA
Provider First Name:
VINCENT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1487632170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
352 S DELSEA DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINELAND
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08360-5306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-690-1616
Provider Business Mailing Address Fax Number:
856-896-6107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
352 S DELSEA DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VINELAND
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08360-5306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-690-1616
Provider Business Practice Location Address Fax Number:
856-896-6107
Provider Enumeration Date:
01/04/2006

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: 207RS0010X , with the licence number:  C2-0005338 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0010X , with the licence number: 25MB06246100 , 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: 5091134 . This is a "CIGNA" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 981003 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1316962 . This is a "AETNA HMO" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 204753265 . This is a "TRICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 3156674 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2803741000 . This is a "AMERIHEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 204753265 . This is a "BLUE CROSS BLUE SHEILD DE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 2803109000 . This is a "INDEPENDENCE BLUE CROSS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 442146 . This is a "COVENTRY" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 5933380 . This is a "AETNA PPO" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 20-4753265 . This is a "NATIONAL PROVIDER NETWORK" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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