Provider Demographics
NPI:1417915968
Name:AVERSA, THADDEUS M (DO)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:M
Last Name:AVERSA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27957
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0957
Mailing Address - Country:US
Mailing Address - Phone:908-835-1910
Mailing Address - Fax:908-835-1924
Practice Address - Street 1:410 COVENTRY CENTRE DR
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865
Practice Address - Country:US
Practice Address - Phone:908-454-9902
Practice Address - Fax:908-454-9905
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB065920207Q00000X
PAOS008958L207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0963243OtherAETNA
NJ7437307Medicaid
NJ223733353OtherHORIZON
NJ223733353OtherHORIZON
NJ901263Medicare PIN