Provider Demographics
NPI:1104830629
Name:PANETTIERI, REYNOLD A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNOLD
Middle Name:A
Last Name:PANETTIERI
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4947
Mailing Address - Country:US
Mailing Address - Phone:201-759-6921
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:125 PATERSON ST STE 5100
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1962
Practice Address - Country:US
Practice Address - Phone:732-235-7840
Practice Address - Fax:732-235-6524
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA09773100207R00000X, 207RP1001X
PAMD032459E207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011230140001Medicaid
PA0011230140001Medicaid
PA531005Medicare ID - Type Unspecified