Healthcare Provider Details

I. General information

NPI: 1164788501
Provider Name (Legal Business Name): ERIC ROBERT REQUA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 ROUTE 73 N LOWR LEVEL
MARLTON NJ
08053-4524
US

IV. Provider business mailing address

2000 CRAWFORD PL STE 200
MOUNT LAUREL NJ
08054-3954
US

V. Phone/Fax

Practice location:
  • Phone: 844-908-5483
  • Fax: 856-355-7106
Mailing address:
  • Phone: 856-355-0340
  • Fax: 856-355-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS017463
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB09913200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: