Healthcare Provider Details

I. General information

NPI: 1710944194
Provider Name (Legal Business Name): CYNTHIA CARROLE SAGULLO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19-21 FAIR LAWN AVE
FAIR LAWN NJ
07410-2331
US

IV. Provider business mailing address

258 GODWIN AVE
WYCKOFF NJ
07481
US

V. Phone/Fax

Practice location:
  • Phone: 201-254-0260
  • Fax: 844-262-9607
Mailing address:
  • Phone: 201-891-3336
  • Fax: 201-891-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number25MA07103800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: