Provider Demographics
NPI:1770674616
Name:DI MEDIO, MARK ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:DI MEDIO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SICKLERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094
Mailing Address - Country:US
Mailing Address - Phone:856-629-0645
Mailing Address - Fax:856-629-1472
Practice Address - Street 1:500 SICKLERVILLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094
Practice Address - Country:US
Practice Address - Phone:856-629-0645
Practice Address - Fax:856-629-1472
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD001496213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1220501Medicaid
NJ1220501Medicaid
T44787Medicare UPIN