Healthcare Provider Details

I. General information

NPI: 1295767804
Provider Name (Legal Business Name): JOSEPH VINCENT DITROLIO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

556 EAGLE ROCK AVENUE SUITE 204
ROSELAND NJ
07068-1502
US

IV. Provider business mailing address

556 EAGLE ROCK AVENUE SUITE 204
ROSELAND NJ
07068-1502
US

V. Phone/Fax

Practice location:
  • Phone: 973-228-2771
  • Fax: 973-228-7477
Mailing address:
  • Phone: 973-228-2771
  • Fax: 973-228-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA03785200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: