Provider Demographics
NPI:1245217751
Name:RESTIVO, CARL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:RESTIVO
Suffix:JR
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 1:3 WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307
Mailing Address - Country:US
Mailing Address - Phone:201-798-2900
Mailing Address - Fax:201-798-3582
Practice Address - Street 1:3 WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307
Practice Address - Country:US
Practice Address - Phone:201-798-2900
Practice Address - Fax:201-798-3582
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03328700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44466385JMedicaid
460227Medicare ID - Type Unspecified
C56204Medicare UPIN