Provider Demographics
NPI:1689645806
Name:BRUNETTO, JACQUELINE G (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:G
Last Name:BRUNETTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:GERARDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:804 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-7272
Mailing Address - Country:US
Mailing Address - Phone:732-531-0010
Mailing Address - Fax:732-493-0903
Practice Address - Street 1:804 W PARK AVE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-7272
Practice Address - Country:US
Practice Address - Phone:732-531-0010
Practice Address - Fax:732-493-0903
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMAO6712100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7988907Medicaid