Healthcare Provider Details

I. General information

NPI: 1306931837
Provider Name (Legal Business Name): JAMES VINCENT AGRESTI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 KENILWORTH BOULEVARD
KENILWORTH NJ
07033-1616
US

IV. Provider business mailing address

609 KENILWORTH BOULEVARD
KENILWORTH NJ
07033-1616
US

V. Phone/Fax

Practice location:
  • Phone: 908-272-0777
  • Fax: 908-272-6064
Mailing address:
  • Phone: 908-272-0777
  • Fax: 908-272-6064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MB04626400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: