Provider Demographics
NPI:1104810936
Name:OSORIO, JORGE H (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:H
Last Name:OSORIO
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 1:66 W GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:732-212-0060
Mailing Address - Fax:
Practice Address - Street 1:155 JEFFERSON ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1706
Practice Address - Country:US
Practice Address - Phone:973-344-5498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ6847901207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6847901Medicaid
NJ831164DPLMedicare PIN
NJG21216Medicare UPIN
NJ831164Medicare ID - Type Unspecified
NJ831164CLDMedicare PIN
NJ6847901Medicaid
NJ831164DPHMedicare PIN