Provider Demographics
NPI:1336164268
Name:DEPATIVO, ANTHONY CARL (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:CARL
Last Name:DEPATIVO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ANTHONY
Other - Middle Name:CARL
Other - Last Name:DEPATIVO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1202 HADDONFIELD BERLIN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4850
Mailing Address - Country:US
Mailing Address - Phone:856-768-1020
Mailing Address - Fax:
Practice Address - Street 1:1202 HADDONFIELD BERLIN RD
Practice Address - Street 2:SUITE A
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4850
Practice Address - Country:US
Practice Address - Phone:856-768-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC03883111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU31270Medicare UPIN