Provider Demographics
NPI:1740289875
Name:SQUILLARO, ANTHONY J (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:SQUILLARO
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 1:301 BINGHAM AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4700
Mailing Address - Country:US
Mailing Address - Phone:732-775-9077
Mailing Address - Fax:732-988-7852
Practice Address - Street 1:301 BINGHAM AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-4700
Practice Address - Country:US
Practice Address - Phone:732-775-9077
Practice Address - Fax:732-988-7852
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA49021208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1566105Medicaid
633302CLBMedicare ID - Type Unspecified
NJ1566105Medicaid
NJ633302CLBMedicare PIN
G01885Medicare UPIN