Provider Demographics
NPI:1063411957
Name:CRISCITO, MARIO A (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:A
Last Name:CRISCITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:50 NEWARK AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1185
Mailing Address - Country:US
Mailing Address - Phone:973-450-2158
Mailing Address - Fax:973-450-2027
Practice Address - Street 1:50 NEWARK AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1185
Practice Address - Country:US
Practice Address - Phone:973-450-2158
Practice Address - Fax:973-450-2027
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02510600207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1458400Medicaid
NJC58391Medicare UPIN
NJ1458400Medicaid