Provider Demographics
NPI:1578547311
Name:CHIDYLLO, STEPHEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:CHIDYLLO
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 1:8 JUDITH COURT
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712
Mailing Address - Country:US
Mailing Address - Phone:732-859-1156
Mailing Address - Fax:732-605-5959
Practice Address - Street 1:8 JUDITH COURT
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712
Practice Address - Country:US
Practice Address - Phone:732-859-1156
Practice Address - Fax:732-605-5959
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA059051002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCH489700Medicare ID - Type Unspecified
NJF49668Medicare UPIN