Provider Demographics
NPI:1518901925
Name:PERSICHETTI, GREGORY BLASE (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:BLASE
Last Name:PERSICHETTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 KINGS WAY E
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2237
Mailing Address - Country:US
Mailing Address - Phone:856-589-3331
Mailing Address - Fax:856-589-3416
Practice Address - Street 1:100 KINGS WAY E
Practice Address - Street 2:SUITE A-3
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2237
Practice Address - Country:US
Practice Address - Phone:856-589-3331
Practice Address - Fax:856-589-3416
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08242000207ND0101X
PA08012552207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
116873Medicare PIN