Provider Demographics
NPI:1104073584
Name:CARMINE J. DEFUSCO, M.D., P.A.
Entity type:Organization
Organization Name:CARMINE J. DEFUSCO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMINE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DEFUSCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-462-0666
Mailing Address - Street 1:224 TAYLORS MILLS RD
Mailing Address - Street 2:106
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3281
Mailing Address - Country:US
Mailing Address - Phone:732-462-0666
Mailing Address - Fax:732-462-0992
Practice Address - Street 1:224 TAYLORS MILLS RD
Practice Address - Street 2:106
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-3281
Practice Address - Country:US
Practice Address - Phone:732-462-0666
Practice Address - Fax:732-462-0992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03532000207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0179507Medicaid
NJ0179507Medicaid
NJC55505Medicare UPIN