Basic Information
| Provider Information | |||||||||
| NPI: | 1295715787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTAGNOLLI | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 E LAUREL RD STE 1800 | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565666419 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD STE 1800 | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565666419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MB04458900 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7634501 | 05 | NJ | MEDICAID | 104946CKP | 01 | NJ | MEDICARE ID | OTHER |