Healthcare Provider Details

I. General information

NPI: 1518901925
Provider Name (Legal Business Name): GREGORY BLASE PERSICHETTI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KINGS WAY E SUITE A-3
SEWELL NJ
08080-2237
US

IV. Provider business mailing address

100 KINGS WAY E SUITE A-3
SEWELL NJ
08080-2237
US

V. Phone/Fax

Practice location:
  • Phone: 856-589-3331
  • Fax: 856-589-3416
Mailing address:
  • Phone: 856-589-3331
  • Fax: 856-589-3416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number25MB08242000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number08012552
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: