Provider Demographics
NPI:1164788501
Name:REQUA, ERIC ROBERT (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:ROBERT
Last Name:REQUA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CRAWFORD PL STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3954
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:1001 ROUTE 73 N LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4524
Practice Address - Country:US
Practice Address - Phone:844-908-5483
Practice Address - Fax:856-355-7106
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS017463207Q00000X
NJ25MB09913200207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103025113Medicaid
PA103056183Medicaid
PA420854EZ3Medicare PIN
PA103025113Medicaid