Healthcare Provider Details

I. General information

NPI: 1306208764
Provider Name (Legal Business Name): MARIELLA DISTURCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MOHAWK AVE
SPARTA NJ
07871-1808
US

IV. Provider business mailing address

316 CAMBOURNE DR
TOMS RIVER NJ
08753-1903
US

V. Phone/Fax

Practice location:
  • Phone: 973-729-4211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA12156300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: