Provider Demographics
NPI:1346467990
Name:BERTOLINO, ANGELO ANTHONY JR (DC)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:ANTHONY
Last Name:BERTOLINO
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01930-4014
Mailing Address - Country:US
Mailing Address - Phone:978-281-1828
Mailing Address - Fax:
Practice Address - Street 1:357 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-4014
Practice Address - Country:US
Practice Address - Phone:978-281-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1600176Medicaid
MA453911OtherTUFTS
MAY45426OtherBLUE CROSS
MAU38527Medicare UPIN
MA1600176Medicaid