Provider Demographics
NPI:1568467058
Name:TUMILLO, JOHN G JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:TUMILLO
Suffix:JR
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 1:16 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08008-5337
Mailing Address - Country:US
Mailing Address - Phone:609-709-5158
Mailing Address - Fax:
Practice Address - Street 1:301 EAST 17TH ST
Practice Address - Street 2:
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:08050-2412
Practice Address - Country:US
Practice Address - Phone:212-598-6085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06529600207L00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7371403Medicaid
NJ7371403Medicaid
NJ000137Medicare ID - Type Unspecified