Provider Demographics
NPI:1831243682
Name:INTILI, JOHN JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:INTILI
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 1:751 FISCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-4662
Mailing Address - Country:US
Mailing Address - Phone:732-929-4566
Mailing Address - Fax:732-929-4450
Practice Address - Street 1:751 FISCHER BLVD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-4662
Practice Address - Country:US
Practice Address - Phone:732-929-4566
Practice Address - Fax:732-929-4450
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO610562080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6321704Medicare UPIN