Provider Demographics
NPI:1013188655
Name:NEW JERSEY PREVENTIVE CARDIOLOGY
Entity Type:Organization
Organization Name:NEW JERSEY PREVENTIVE CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEGOMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-396-6363
Mailing Address - Street 1:416 BELLEVUE AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08618-4513
Mailing Address - Country:US
Mailing Address - Phone:609-396-6363
Mailing Address - Fax:609-695-7747
Practice Address - Street 1:416 BELLEVUE AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-4513
Practice Address - Country:US
Practice Address - Phone:609-396-6363
Practice Address - Fax:609-695-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA31053207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC56553Medicare UPIN
078156Medicare PIN