Healthcare Provider Details

I. General information

NPI: 1215960752
Provider Name (Legal Business Name): GARDEN STATE MEDICAL ASSOC P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICK RD SUITE 209
MARLTON NJ
08053-2146
US

IV. Provider business mailing address

100 BRICK RD SUITE 209
MARLTON NJ
08053-2146
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-2848
  • Fax: 856-985-7645
Mailing address:
  • Phone: 856-983-2848
  • Fax: 856-985-7645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: DR. JESSE VITO LOMONACO
Title or Position: VICE PRESIDENT
Credential: D.O.
Phone: 856-983-2848