Provider Demographics
NPI:1871632075
Name:CODELLA FAMILY PRACTICE
Entity Type:Organization
Organization Name:CODELLA FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:CODELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-688-1550
Mailing Address - Street 1:1050 GALLOPING HILL ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:908-688-1550
Mailing Address - Fax:908-688-1552
Practice Address - Street 1:1050 GALLOPING HILL ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:908-688-1550
Practice Address - Fax:908-688-1552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB074566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0047171Medicaid
NJ0047198Medicaid
NJ0047171Medicaid
NJ08648Medicare ID - Type UnspecifiedGROUP #
NJ0047198Medicaid