Healthcare Provider Details

I. General information

NPI: 1245357276
Provider Name (Legal Business Name): ERIC BENTOLILA, M.D. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 FRANKLIN TURNPIKE
RIDGEWOOD NJ
07450-0745
US

IV. Provider business mailing address

150 FRANKLIN AVE
RIDGEWOOD NJ
07450-3206
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-1700
  • Fax: 201-447-9386
Mailing address:
  • Phone: 201-447-1700
  • Fax: 201-447-9386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07057600
License Number StateNJ

VIII. Authorized Official

Name: CLARISSA VEGA
Title or Position: OFFICE MANAGER
Credential:
Phone: 973-874-8459