Provider Demographics
NPI:1508880717
Name:REGIS, JON M (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:M
Last Name:REGIS
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 1:525 TILTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1217
Mailing Address - Country:US
Mailing Address - Phone:609-272-0655
Mailing Address - Fax:
Practice Address - Street 1:53 W WHITE HORSE PIKE
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9450
Practice Address - Country:US
Practice Address - Phone:609-652-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03856300207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3585204Medicaid
NJ3585204Medicaid
NJC57118Medicare UPIN