Provider Demographics
NPI:1760590251
Name:PONTECORVO, MARTIN PONTECORVO (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:PONTECORVO
Last Name:PONTECORVO
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 1:1072 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:STIRLING
Mailing Address - State:NJ
Mailing Address - Zip Code:07980-1518
Mailing Address - Country:US
Mailing Address - Phone:908-604-8464
Mailing Address - Fax:908-604-2494
Practice Address - Street 1:1072 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STIRLING
Practice Address - State:NJ
Practice Address - Zip Code:07980-1518
Practice Address - Country:US
Practice Address - Phone:973-514-1767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05504200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF27188Medicare UPIN
NJ722138Medicare ID - Type Unspecified