Provider Demographics
NPI:1063670131
Name:PASSALAQUA, PHILIP ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ANTHONY
Last Name:PASSALAQUA
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 1:311 CRESCENT PKWY
Mailing Address - Street 2:
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750-3015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 CRESCENT PKWY
Practice Address - Street 2:
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-3015
Practice Address - Country:US
Practice Address - Phone:732-974-0437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02052200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine