Provider Demographics
NPI:1083664197
Name:SELVAGGI, THOMAS AQUINAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:AQUINAS
Last Name:SELVAGGI
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 1:211 ESSEX ST
Mailing Address - Street 2:STE 401
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-3246
Mailing Address - Country:US
Mailing Address - Phone:201-343-6673
Mailing Address - Fax:201-343-7555
Practice Address - Street 1:211 ESSEX ST
Practice Address - Street 2:SUITE 205
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-3231
Practice Address - Country:US
Practice Address - Phone:201-343-6673
Practice Address - Fax:201-343-7555
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06521100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G61373Medicare UPIN
001506Medicare ID - Type Unspecified