Provider Demographics
NPI:1285654582
Name:DEPATIVO, CARL ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ANTHONY
Last Name:DEPATIVO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:CARL
Other - Middle Name:ANTHONY
Other - Last Name:DEPATIVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:15 EASY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE MAY COURT HOUSE
Mailing Address - State:NJ
Mailing Address - Zip Code:08210-1949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 W WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009-2003
Practice Address - Country:US
Practice Address - Phone:856-768-1020
Practice Address - Fax:856-768-1021
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001146L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT44722Medicare UPIN
NJ115893Medicare ID - Type Unspecified