Provider Demographics
NPI:1891815098
Name:FORMISANO, EDWARD PETER (DC)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:PETER
Last Name:FORMISANO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 BUDD AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07930-2506
Mailing Address - Country:US
Mailing Address - Phone:908-879-8709
Mailing Address - Fax:908-879-8909
Practice Address - Street 1:32 BUDD AVE
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2506
Practice Address - Country:US
Practice Address - Phone:908-879-8709
Practice Address - Fax:908-879-8909
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00363800111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7006608Medicaid
NJ7006608Medicaid