Provider Demographics
NPI:1194724195
Name:DEGOMA, ROLANDO L (MD)
Entity type:Individual
Prefix:DR
First Name:ROLANDO
Middle Name:L
Last Name:DEGOMA
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 1:416 BELLEVUE AVE
Mailing Address - Street 2:STE 303
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-4513
Mailing Address - Country:US
Mailing Address - Phone:609-396-6363
Mailing Address - Fax:609-695-7747
Practice Address - Street 1:416 BELLEVUE AVE
Practice Address - Street 2:STE 303
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-4513
Practice Address - Country:US
Practice Address - Phone:609-396-6363
Practice Address - Fax:609-695-7747
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA31053207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2504308Medicaid
NJ2504308Medicaid
502092SNQMedicare ID - Type Unspecified