Provider Demographics
NPI:1467496687
Name:DEPACE, NICHOLAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:L
Last Name:DEPACE
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 1:438 GANTTOWN RD
Mailing Address - Street 2:SUITES B8-B9
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-1887
Mailing Address - Country:US
Mailing Address - Phone:856-589-6034
Mailing Address - Fax:856-589-6036
Practice Address - Street 1:438 GANTTOWN RD
Practice Address - Street 2:SUITES B8-B9
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-589-6034
Practice Address - Fax:856-589-6036
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03627300207R00000X, 207UN0901X, 207RC0000X
PAMD023597E207R00000X, 207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0229598000OtherKEYSTONE HEALTH PLAN EAST
NJ1048118OtherHORIZON NJ HEALTH
NJ4100717OtherAETNA
NJ530072OtherUNITED HEALTHCARE
NJP3785506OtherOXFORD
NJ0229598000OtherPERSONAL CHOICE
NJ5264103Medicaid
NJ01004610300OtherAMERICHOICE
NJ0229598000OtherAMERIHEALTH
NJ0154010OtherGHI
NJ0154010OtherGHI
NJ0229598000OtherKEYSTONE HEALTH PLAN EAST
NJ4100717OtherAETNA
PA178601YAJZMedicare PIN
PA189471YHB6Medicare PIN