Provider Demographics
NPI:1396807145
Name:GERVASONI, JAMES E JR (MD,)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:E
Last Name:GERVASONI
Suffix:JR
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1766
Mailing Address - Country:US
Mailing Address - Phone:732-745-8600
Mailing Address - Fax:732-249-5284
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1766
Practice Address - Country:US
Practice Address - Phone:732-745-8600
Practice Address - Fax:732-249-5284
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA7045600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG82447Medicare UPIN