Healthcare Provider Details

I. General information

NPI: 1184622748
Provider Name (Legal Business Name): JOHN A MOSOLINO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 ABBOTT BLVD SUITE G-1
FORT LEE NJ
07024-4151
US

IV. Provider business mailing address

810 ABBOTT BLVD SUITE G-1
FORT LEE NJ
07024-4151
US

V. Phone/Fax

Practice location:
  • Phone: 201-224-0255
  • Fax: 201-224-0395
Mailing address:
  • Phone: 201-224-0255
  • Fax: 201-224-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00122300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: