Provider Demographics
NPI:1669664298
Name:PERRIL, REBECCA (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:PERRIL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 ROUTE 66
Mailing Address - Street 2:SUITE 125
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-7300
Mailing Address - Country:US
Mailing Address - Phone:732-922-2105
Mailing Address - Fax:732-922-2472
Practice Address - Street 1:4000 ROUTE 66
Practice Address - Street 2:SUITE 125
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-7300
Practice Address - Country:US
Practice Address - Phone:732-922-2105
Practice Address - Fax:732-922-2472
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB082215002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0249190Medicaid