Provider Demographics
NPI:1790859494
Name:GENNARO, ANTHONY J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:J
Last Name:GENNARO
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 1:413 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1423
Mailing Address - Country:US
Mailing Address - Phone:201-288-6335
Mailing Address - Fax:201-393-0890
Practice Address - Street 1:413 BOULEVARD
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-1423
Practice Address - Country:US
Practice Address - Phone:201-288-6335
Practice Address - Fax:201-393-0890
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03468400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1278401Medicaid
NJC54707Medicare UPIN
NJ1278401Medicaid