Provider Demographics
NPI:1144206384
Name:BISPO, LUCIANO J (MD)
Entity Type:Individual
Prefix:
First Name:LUCIANO
Middle Name:J
Last Name:BISPO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:227 LAUREL RD
Mailing Address - Street 2:STE 300
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-8303
Mailing Address - Country:US
Mailing Address - Phone:856-669-6050
Mailing Address - Fax:856-651-0794
Practice Address - Street 1:2950 COLLEGE DR
Practice Address - Street 2:STE 2F
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6933
Practice Address - Country:US
Practice Address - Phone:856-205-0606
Practice Address - Fax:856-205-0044
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2011-11-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA07269600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8949107Medicaid
NJ065086Medicare PIN