Provider Demographics
NPI:1265505630
Name:NARDOLILLO, ROBERT S (DPM)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:NARDOLILLO
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 1:674 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4202
Mailing Address - Country:US
Mailing Address - Phone:732-933-0370
Mailing Address - Fax:732-933-0390
Practice Address - Street 1:674 BROAD STREET
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702
Practice Address - Country:US
Practice Address - Phone:732-933-0370
Practice Address - Fax:732-933-0390
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00207100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
602697Medicare ID - Type Unspecified
T51024Medicare UPIN