Provider Demographics
NPI:1841338316
Name:RUSTIA-VILLA, MARILOU UDASCO (MD)
Entity type:Individual
Prefix:DR
First Name:MARILOU
Middle Name:UDASCO
Last Name:RUSTIA-VILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PATRICK AVE
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1462
Mailing Address - Country:US
Mailing Address - Phone:201-358-3266
Mailing Address - Fax:201-358-3644
Practice Address - Street 1:250 OLD HOOK RD
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3123
Practice Address - Country:US
Practice Address - Phone:201-358-3266
Practice Address - Fax:201-358-3644
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05387700207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH11743Medicare UPIN