Provider Demographics
NPI:1306931837
Name:AGRESTI, JAMES VINCENT (DO)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:VINCENT
Last Name:AGRESTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 KENILWORTH BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-1616
Mailing Address - Country:US
Mailing Address - Phone:908-272-0777
Mailing Address - Fax:908-272-6064
Practice Address - Street 1:609 KENILWORTH BOULEVARD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1616
Practice Address - Country:US
Practice Address - Phone:908-272-0777
Practice Address - Fax:908-272-6064
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04626400207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1529102Medicaid
NJAG452438Medicare ID - Type Unspecified
NJ1529102Medicaid