Provider Demographics
NPI:1699757898
Name:DESALVO, EUGENE L (MD)
Entity type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:L
Last Name:DESALVO
Suffix:
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 1:515 IRON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5300
Mailing Address - Country:US
Mailing Address - Phone:732-780-3434
Mailing Address - Fax:732-780-9334
Practice Address - Street 1:515 IRON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-5300
Practice Address - Country:US
Practice Address - Phone:732-780-3434
Practice Address - Fax:732-780-9334
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA31852208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3051200Medicaid
NJDE455740Medicare ID - Type Unspecified
D06613Medicare UPIN