Provider Demographics
NPI:1407860760
Name:LUCIANO J. BISPO, MD, LLC
Entity Type:Organization
Organization Name:LUCIANO J. BISPO, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUCIANO
Authorized Official - Middle Name:J
Authorized Official - Last Name:BISPO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-205-0606
Mailing Address - Street 1:175 W COHAWKIN RD STE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08020-1145
Mailing Address - Country:US
Mailing Address - Phone:856-423-7700
Mailing Address - Fax:856-423-0823
Practice Address - Street 1:2950 COLLEGE DR
Practice Address - Street 2:STE 2F
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6933
Practice Address - Country:US
Practice Address - Phone:856-205-0606
Practice Address - Fax:856-205-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07269600207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty