Provider Demographics
NPI:1063488484
Name:DI GUGLIELMO, NICOLA (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:
Last Name:DI GUGLIELMO
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 1:1400 HIGHWAY 35
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3522
Mailing Address - Country:US
Mailing Address - Phone:732-531-5509
Mailing Address - Fax:732-531-5164
Practice Address - Street 1:1400 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-3522
Practice Address - Country:US
Practice Address - Phone:732-531-5509
Practice Address - Fax:732-531-5164
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-25
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA48636207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1702106Medicaid
C56623Medicare UPIN
NJ1702106Medicaid