Provider Demographics
NPI:1316058852
Name:DERMER, ALICIA RAQUEL (MD)
Entity type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:RAQUEL
Last Name:DERMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1001 W MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2579
Mailing Address - Country:US
Mailing Address - Phone:732-294-2540
Mailing Address - Fax:732-294-9328
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2579
Practice Address - Country:US
Practice Address - Phone:732-294-2540
Practice Address - Fax:732-294-9328
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJMA40118207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1226304Medicaid
NJ198014A02Medicare PIN
NJC58769Medicare UPIN