Healthcare Provider Details

I. General information

NPI: 1649470295
Provider Name (Legal Business Name): ROBERT A MUSTILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 CHESTNUT ST
NEWARK NJ
07105-1558
US

IV. Provider business mailing address

221 CHESTNUT ST
NEWARK NJ
07105-1558
US

V. Phone/Fax

Practice location:
  • Phone: 973-878-3990
  • Fax:
Mailing address:
  • Phone: 973-878-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License NumberMA053782
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberMA053782
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMA053782
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: