Provider Demographics
NPI:1235191875
Name:FELICETTA, MICHAEL J
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FELICETTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BEY LEA RD
Mailing Address - Street 2:STE 1
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2978
Mailing Address - Country:US
Mailing Address - Phone:732-505-9728
Mailing Address - Fax:732-505-9787
Practice Address - Street 1:1178 ROUTE 37 W
Practice Address - Street 2:STE 1
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-4920
Practice Address - Country:US
Practice Address - Phone:732-240-5677
Practice Address - Fax:732-240-0926
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD00111300213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0990906Medicaid
NJ6202320001Medicare NSC
NJT73058Medicare UPIN
NJ0990906Medicaid