Provider Demographics
NPI:1124025820
Name:PELOSI, JOHN E (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:PELOSI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1633
Mailing Address - Country:US
Mailing Address - Phone:856-881-2525
Mailing Address - Fax:856-881-0734
Practice Address - Street 1:411 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-1633
Practice Address - Country:US
Practice Address - Phone:856-881-2525
Practice Address - Fax:856-881-0734
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002642213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8622302Medicaid
NJU85865Medicare UPIN
NJ049310Medicare ID - Type Unspecified