Provider Demographics
NPI:1750314274
Name:LOMONACO, JESSE VITO (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:VITO
Last Name:LOMONACO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BRICK RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2146
Mailing Address - Country:US
Mailing Address - Phone:856-983-2848
Mailing Address - Fax:856-985-7645
Practice Address - Street 1:100 BRICK RD
Practice Address - Street 2:SUITE 209
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2146
Practice Address - Country:US
Practice Address - Phone:856-983-2848
Practice Address - Fax:856-985-7645
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB26031204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2400707Medicaid
NJLO602292Medicare ID - Type Unspecified
NJC54234Medicare UPIN