Provider Demographics
NPI:1275961443
Name:A.N. HORMILLA, MDPA
Entity Type:Organization
Organization Name:A.N. HORMILLA, MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMADOR
Authorized Official - Middle Name:N
Authorized Official - Last Name:HORMILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-505-0500
Mailing Address - Street 1:508 LAKEHURST RD
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755
Mailing Address - Country:US
Mailing Address - Phone:732-505-0500
Mailing Address - Fax:732-505-0295
Practice Address - Street 1:508 LAKEHURST RD.
Practice Address - Street 2:SUITE 3B
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755
Practice Address - Country:US
Practice Address - Phone:732-505-0500
Practice Address - Fax:732-505-0295
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A.N. HORMILLA,MDPA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA4576000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3615006Medicaid