Provider Demographics
NPI:1750347449
Name:BELLAVIA, THOMAS SALVATORE (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:SALVATORE
Last Name:BELLAVIA
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 1:288 BOULEVARD STE 2
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-1319
Mailing Address - Country:US
Mailing Address - Phone:201-288-6781
Mailing Address - Fax:201-288-2734
Practice Address - Street 1:288 BOULEVARD STE 2
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604-1319
Practice Address - Country:US
Practice Address - Phone:201-288-6781
Practice Address - Fax:201-288-2734
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ21636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0956201Medicaid
NJ0956201Medicaid
405512BMTMedicare ID - Type Unspecified