Provider Demographics
NPI:1437200441
Name:CAPISTRANO, CECILIO L (MD)
Entity Type:Individual
Prefix:DR
First Name:CECILIO
Middle Name:L
Last Name:CAPISTRANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 WOLVERTON PL
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-5237
Mailing Address - Country:US
Mailing Address - Phone:856-764-7853
Mailing Address - Fax:
Practice Address - Street 1:510 HERON DR
Practice Address - Street 2:SUITE 108
Practice Address - City:BRIDGEPORT
Practice Address - State:NJ
Practice Address - Zip Code:08014
Practice Address - Country:US
Practice Address - Phone:856-467-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA26565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJB34092Medicare UPIN
NJ039801Medicare ID - Type Unspecified