Provider Demographics
NPI:1336189786
Name:IMPEDUGLIA, THERESA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARIE
Last Name:IMPEDUGLIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1262
Mailing Address - Country:US
Mailing Address - Phone:201-646-0010
Mailing Address - Fax:201-646-0600
Practice Address - Street 1:83 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1262
Practice Address - Country:US
Practice Address - Phone:201-646-0010
Practice Address - Fax:201-646-0600
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1951342086S0129X
NJMA726682086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03817627Medicaid
NJG81847Medicare UPIN
NY03817627Medicaid