Provider Demographics
NPI:1962442194
Name:RACANIELLO, ANGELO R (MD)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:R
Last Name:RACANIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:877-751-1157
Mailing Address - Fax:919-425-0478
Practice Address - Street 1:308 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-3808
Practice Address - Country:US
Practice Address - Phone:919-425-1565
Practice Address - Fax:919-425-0478
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA46152207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6388108Medicaid
NJ6388108Medicaid
D99718Medicare UPIN