Provider Demographics
NPI:1184738940
Name:DETULLIO, JOHN P (MD, FCCP)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:DETULLIO
Suffix:
Gender:M
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:901 W MAIN ST
Mailing Address - Street 2:SUITE 160, CN 5050
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2537
Mailing Address - Country:US
Mailing Address - Phone:732-577-0600
Mailing Address - Fax:732-577-6332
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:SUITE 160, CN 5050
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-577-0600
Practice Address - Fax:732-577-6332
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04345700207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03F88OtherEMPIRE BCBS
NJ1431005Medicaid
NJ110098315OtherMEDICARE RAILROAD
NJ41014OtherAETNA
NJMS044OtherOXFORD
NJ4093697OtherAETNA
NJ223019073-002OtherQUALCARE
NJF00797OtherHEALTH NET OF NJ
NJ223019073OtherTAX IDENTIFICATION NUMBER
NJ223019073-002OtherST. BARNABAS HEALTH PLAN
NJ41014OtherAETNA
NJ223019073-002OtherQUALCARE