Provider Demographics
NPI:1679133961
Name:CAPUANO, MARY ELLEN
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:CAPUANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NJ
Mailing Address - Zip Code:08240-0788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-1462
Practice Address - Country:US
Practice Address - Phone:302-645-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ6261792085R0204X, 156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology