Provider Demographics
NPI:1285614800
Name:MIGUELINO, IDA A (MD)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:A
Last Name:MIGUELINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DIAMOND HILL RD
Mailing Address - Street 2:SUMMIT MEDICAL GROUP
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:908-769-2516
Practice Address - Street 1:1 DIAMOND HILL RD
Practice Address - Street 2:SUMMIT MEDICAL GROUP
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-2104
Practice Address - Country:US
Practice Address - Phone:908-273-4300
Practice Address - Fax:908-769-2516
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA65729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ012165BSDMedicare ID - Type UnspecifiedMEDICARE#
NJG74788Medicare UPIN