Provider Demographics
NPI:1790779833
Name:BELLOMO, SPARTACO (MDPA)
Entity Type:Individual
Prefix:DR
First Name:SPARTACO
Middle Name:
Last Name:BELLOMO
Suffix:
Gender:M
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 PALISADE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-1133
Mailing Address - Country:US
Mailing Address - Phone:201-653-8336
Mailing Address - Fax:201-653-6697
Practice Address - Street 1:142 PALISADE AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1133
Practice Address - Country:US
Practice Address - Phone:201-653-8336
Practice Address - Fax:201-653-6697
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ MA 39880207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1425706Medicaid
NJ1425706Medicaid