Healthcare Provider Details

I. General information

NPI: 1518971068
Provider Name (Legal Business Name): MARIA BOCCALETTI VISCUSO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HEDDEN TERRACE
NORTH ARLINGTON NJ
07031-6109
US

IV. Provider business mailing address

85 S JEFFERSON ST STE. 1
ORANGE NJ
07050-1562
US

V. Phone/Fax

Practice location:
  • Phone: 201-991-5353
  • Fax: 201-991-0587
Mailing address:
  • Phone: 973-677-3466
  • Fax: 973-677-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA04319400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: