Provider Demographics
NPI:1306802988
Name:DELRE, SALLUSTIO (MD)
Entity type:Individual
Prefix:
First Name:SALLUSTIO
Middle Name:
Last Name:DELRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:155 MEDICAL CENTER WAY
Mailing Address - Street 2:3RD FL
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2306
Mailing Address - Country:US
Mailing Address - Phone:609-365-3100
Mailing Address - Fax:609-365-3165
Practice Address - Street 1:155 MEDICAL CENTER WAY
Practice Address - Street 2:3RD FL
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2306
Practice Address - Country:US
Practice Address - Phone:609-365-3100
Practice Address - Fax:609-365-3165
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA05938000207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7849206Medicaid
F73097Medicare UPIN
NJ020167Medicare ID - Type Unspecified