Provider Demographics
NPI:1356319735
Name:IETTA, MICHAEL ANGELO (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANGELO
Last Name:IETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:71 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1405
Mailing Address - Country:US
Mailing Address - Phone:201-251-2213
Mailing Address - Fax:201-251-2279
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:SUITE 16
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1439
Practice Address - Country:US
Practice Address - Phone:201-847-9403
Practice Address - Fax:201-847-0059
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA56733207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5508207Medicaid
NJ687629DMFMedicare ID - Type Unspecified
NJ5508207Medicaid