MEDICARE: DR. ERIC ROBERT REQUA D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS017463	PA
2	207QS0010X	Sports Medicine (Family Medicine) Physician	25MB09913200	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164788501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC ROBERT REQUA D.O.

Provider Business Mailing Address
First Line	:	2000 CRAWFORD PL STE 200
Second Line	:
City	:	MOUNT LAUREL
State	:	NJ
Zip	:	08054-3954
Country	:	US
Telephone Number	:	856-355-0340
Fax Number	:	856-355-0330

Provider Business Practice Location Address
First Line	:	1001 ROUTE 73 N LOWR LEVEL
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-4524
Country	:	US
Telephone Number	:	844-908-5483
Fax Number	:	856-355-7106

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2012
Last Update Date	:	10/15/2020

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