Provider Demographics
NPI:1801829890
Name:VINCENT DESTASIO DO LLC
Entity Type:Organization
Organization Name:VINCENT DESTASIO DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:BACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-255-6566
Mailing Address - Street 1:1851 HOOPER AVE
Mailing Address - Street 2:ST A
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8150
Mailing Address - Country:US
Mailing Address - Phone:732-255-6566
Mailing Address - Fax:732-255-3085
Practice Address - Street 1:1851 HOOPER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-8150
Practice Address - Country:US
Practice Address - Phone:732-255-6566
Practice Address - Fax:732-255-3085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ610933W3ZMedicare PIN
NJ116263W3ZMedicare PIN