Provider Demographics
NPI:1114954054
Name:VILLARE, ANTHONY WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:WILLIAM
Last Name:VILLARE
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 1:560 MANTUA AVE
Mailing Address - Street 2:
Mailing Address - City:PAULSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08066
Mailing Address - Country:US
Mailing Address - Phone:856-423-5466
Mailing Address - Fax:
Practice Address - Street 1:560 MANTUA AVE
Practice Address - Street 2:
Practice Address - City:PAULSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08066
Practice Address - Country:US
Practice Address - Phone:856-423-5466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA57364207Q00000X
PAMD039413L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1638203Medicaid
NJ453306Medicare ID - Type Unspecified
C33120Medicare UPIN
PA188890Medicare PIN