Provider Demographics
NPI:1780731034
Name:CIRAVOLO, LOUIS JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:JOHN
Last Name:CIRAVOLO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 OAKLYN CT
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-1817
Mailing Address - Country:US
Mailing Address - Phone:856-772-2885
Mailing Address - Fax:856-772-2881
Practice Address - Street 1:602 S BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1222
Practice Address - Country:US
Practice Address - Phone:856-963-2266
Practice Address - Fax:856-772-2881
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD02339213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7279302Medicaid
NJ010002883-00OtherAMERICHOICE OF NJ
NJ1107086OtherHORIZON NJ HEALTH
NJU66580Medicare UPIN
NJ951494Medicare ID - Type UnspecifiedMEDICARE