Healthcare Provider Details

I. General information

NPI: 1629047048
Provider Name (Legal Business Name): ANTONIO CAMILO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PASSAIC AVE
PASSAIC NJ
07055-4860
US

IV. Provider business mailing address

80 PASSAIC AVE
PASSAIC NJ
07055-4860
US

V. Phone/Fax

Practice location:
  • Phone: 973-471-1010
  • Fax: 973-471-4951
Mailing address:
  • Phone: 973-471-1010
  • Fax: 973-471-4951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07167400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0083691
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier8407509
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 3
Identifier8407304
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: