Healthcare Provider Details

I. General information

NPI: 1881673275
Provider Name (Legal Business Name): MICHAEL C. DIMARCANGELO JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W MAIN ST SUITE C
MAPLE SHADE NJ
08052-2411
US

IV. Provider business mailing address

303 HIALEAH DR
MOUNT LAUREL NJ
08054-5706
US

V. Phone/Fax

Practice location:
  • Phone: 856-779-7386
  • Fax: 856-779-7563
Mailing address:
  • Phone: 609-779-7386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB04884500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: