Healthcare Provider Details

I. General information

NPI: 1558363382
Provider Name (Legal Business Name): JEROME PUMO JR. D.O.,FACOFP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 08/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 WESTFIELD AVE UNIT 1
CLARK NJ
07066-2453
US

IV. Provider business mailing address

144 KLINE BLVD
COLONIA NJ
07067-1925
US

V. Phone/Fax

Practice location:
  • Phone: 732-574-1777
  • Fax: 732-574-2707
Mailing address:
  • Phone: 732-574-1777
  • Fax: 732-574-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB02746100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: