Provider Demographics
NPI:1649470295
Name:MUSTILLO, ROBERT A (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:MUSTILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-1558
Mailing Address - Country:US
Mailing Address - Phone:973-878-3990
Mailing Address - Fax:
Practice Address - Street 1:221 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1558
Practice Address - Country:US
Practice Address - Phone:973-878-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA053782202C00000X, 204D00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE55343Medicare UPIN