Provider Demographics
NPI:1487754131
Name:BEVILACQUA, NICHOLAS JOSEPH (DPM)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:BEVILACQUA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-3144
Mailing Address - Country:US
Mailing Address - Phone:201-353-9000
Mailing Address - Fax:
Practice Address - Street 1:730 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-3144
Practice Address - Country:US
Practice Address - Phone:201-353-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00304300213ES0103X, 213ES0103X
NYN006135213ES0103X
IA000802213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ185022BMPMedicare PIN