Provider Demographics
NPI:1174528996
Name:BERTOLUCCI, ALESSANDRA (MD)
Entity type:Individual
Prefix:
First Name:ALESSANDRA
Middle Name:
Last Name:BERTOLUCCI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 CLIFTON AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3517
Mailing Address - Country:US
Mailing Address - Phone:973-472-6405
Mailing Address - Fax:973-472-6406
Practice Address - Street 1:1033 CLIFTON AVE STE 107
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3517
Practice Address - Country:US
Practice Address - Phone:973-773-9882
Practice Address - Fax:973-773-9883
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07279200207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9068805Medicaid
NJ063654Medicare UPIN
NJ063654ZCSYMedicare PIN