Provider Demographics
NPI:1467553172
Name:VISCUSO, RONALD L (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:L
Last Name:VISCUSO
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 1:83 HANOVER ROAD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-1520
Mailing Address - Country:US
Mailing Address - Phone:973-736-2212
Mailing Address - Fax:973-736-2989
Practice Address - Street 1:83 HANOVER ROAD
Practice Address - Street 2:SUITE 290
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1520
Practice Address - Country:US
Practice Address - Phone:973-736-2212
Practice Address - Fax:973-736-2989
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02403300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1121901Medicaid
C55033Medicare UPIN
NJ450119A4GMedicare ID - Type Unspecified