Provider Demographics
NPI:1376683979
Name:DE MARCO, MICHAEL JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:DE MARCO
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 1:13 BLUEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-9731
Mailing Address - Country:US
Mailing Address - Phone:732-922-3313
Mailing Address - Fax:
Practice Address - Street 1:13 BLUEBERRY LN
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-9731
Practice Address - Country:US
Practice Address - Phone:732-922-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD001764213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0905208Medicaid
589600Medicare ID - Type UnspecifiedMEDICARE
NJ0905208Medicaid