Provider Demographics
NPI:1790823755
Name:AVALLONE, NICHOLAS J (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:AVALLONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRASS CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882-6309
Mailing Address - Country:US
Mailing Address - Phone:908-859-8884
Mailing Address - Fax:908-859-6841
Practice Address - Street 1:755 MEMORIAL PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865-2748
Practice Address - Country:US
Practice Address - Phone:908-859-8884
Practice Address - Fax:908-859-6841
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08202400207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0294471Medicaid
NJ0294471Medicaid
PA111570Medicare PIN