Healthcare Provider Details

I. General information

NPI: 1750314274
Provider Name (Legal Business Name): JESSE VITO LOMONACO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 E MAIN ST
MARLTON NJ
08053-2185
US

IV. Provider business mailing address

100 BRICK RD SUITE 209
MARLTON NJ
08053-2146
US

V. Phone/Fax

Practice location:
  • Phone: 856-983-0411
  • Fax: 856-985-4655
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 NumberMB26031
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: