Provider Demographics
NPI:1255389813
Name:AGRESTI, JAMES V III (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:V
Last Name:AGRESTI
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:66 SOMME ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3612
Mailing Address - Country:US
Mailing Address - Phone:973-522-0006
Mailing Address - Fax:973-522-0666
Practice Address - Street 1:181 FRANKLIN AVE
Practice Address - Street 2:#201
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3820
Practice Address - Country:US
Practice Address - Phone:973-284-0777
Practice Address - Fax:973-284-1530
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA0726100207R00000X
NJXA9072240207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0079588Medicaid
NJ0079588Medicaid
NJ085650Medicare ID - Type Unspecified