state of new jersey medicaid fraud division provider ... · ahmad, abadullah 4/3/1984 280 louis...
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
1
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
2258 PHARMACY, INC. 2258 THIRD AVENUE NEW YORK NY 10035 SUSPENSION 7/20/2003
6522 VENTNOR AVE.
PHARMACY, INC.
6522 VENTNOR AVENUE VENTNOR NJ 08406 DISQUALIFICATION
ABARCA, CHERYL R. LPN 8/15/1962 528 3RD STREET NEWARK NJ 07107 SUSPENSION 6/20/2005
ABASHKIN, ROMAN CHHA 12/21/1981 72 RIDGEVIEW TERRACE WAYNE NJ 07470 DISQUALIFICATION 5/29/2015
ABASHKIN, ROMAN CHHA 12/21/1981 72 RIDGEVIEW TERRACE WAYNE NJ 07470 DISQUALIFICATION 6/3/2016
ABBASSI, JADAN MD 9/19/1944 1194807255 1618 MAIN AVENUE CLIFTON NJ 07011 DISQUALIFICATION 11/21/2016 PERMANENT
ABBASSI, JADAN MD 9/19/1944 1194807255 115 NELLIS DRIVE WAYNE NJ 07470 DISQUALIFICATION 6/20/2018 PERMANENT
ABDALLA, IZZELDIN 4/5/1967 1116 ANNE STREET ELIZABETH NJ 07201 DISQUALIFICATION 11/10/1999
ABDELGANI, AMIR ALLENWOOD USP WHITE DEER PA 17887 DISQUALIFICATION 11/26/2001
ABDELGANI, FADIL TERRE HAUTE USP TERRE HAUTE IN 47808 DISQUALIFICATION 11/26/2001
ABDELHAMID, MANAL RPH 5/28/1969 7100 BOULEVARD EAST, 11G GUTTENBERG NJ 07093 DEBARMENT 3/15/2001
ABDOLLAHI, MITRA DMD 8/31/1966 1033329230 646 N. SARATOGA DRIVE MOORESTOWN NJ 08057 DISQUALIFICATION 11/5/2007
ABERBACH, STEVEN RPH 8/5/1944 23 STONEGATE DRIVE WATCHUNG NJ 07069 DEBARMENT 12/19/2003
ABOOD, ABDOLMAID S. 1/20/1966 64 BEVAN STREET JERSEY CITY NJ 07306 SUSPENSION 5/7/1997
ABOODS MEDICAL LIVERY 64 BEVAN STREET JERSEY CITY NJ 07306 DISQUALIFICATION 5/22/1994
ABOUELHODA, AHMED RPH 3/23/1974 33-17 60TH ST., APT. 1 WOODSIDE NY 11377 SUSPENSION 9/20/2005
ABRAHAMSEN, SVEND DPM 9/17/1944 101 CHESTNUT RIDGE RD. SADDLE RIVER NJ 07458 DISQUALIFICATION 4/20/1994
ABRAMS, IRVING RPH 12/23/1949 5 LORGENE WAY MORGANVILLE NJ 07551 SUSPENSION 4/27/2000
ABREU MARTINEZ,
CAROLINA
CHHA 12/14/1989 14 EAST RUSSELL STREET CLIFTON NJ 07011 DEBARMENT 10/31/2017
ABUSEF, ELSAYED K. SUTEX
MED.
TRANSPO
RT
814 74TH STREET NORTH BERGEN NJ 07047 DISQUALIFICATION 5/20/1999
AC HOME NURSING 1235230665 2921 YOUNGSTOWN RD. WARREN OH 44484 DISQUALIFICATION 11/20/2015
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
2
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ACKLEY, GEORGE PSYCH 5/13/1944 1457535833 202 LENOX AVENUE CAPE MAY NJ 08204 DEBARMENT 7/21/2015
ACOSTA, PEDRO E. 1/23/1945 5815 43RD AVENUE WOODSIDE NY 11377 SUSPENSION 4/13/2008
ACOSTA, PEDRO E. 1/23/1945 5815 43RD AVENUE WOODSIDE NY 11377 DISQUALIFICATION 5/2/2008
ACOSTA, PEDRO E. 1/23/1945 5815 43RD AVENUE, 1ST FL WOODSIDE NY 11377 DISQUALIFICATION 9/16/2011
ACOSTA, WILLIAM R. MD 8/24/1949 47 OSBORNE STREET JOHNSTOWN PA 15905 DISQUALIFICATION 11/20/2015
ACQUAIRE, FLORENCE 7/4/1940 EMCF PO BOX 08809 CLINTON NJ 08809 SUSPENSION 4/20/2006
ACQUAYE, EDWARD 2/9/1950 10 BERWICK CIRCLE NORTH BRUNSWICK NJ 08902 SUSPENSION 4/19/2007
ACZON, FERDINAND B. MD 11/29/1948 1255422135 204 SUMMIT RD. MOUNT LAUREL NJ 08054 DISQUALIFICATION 9/20/2011 11/23/2016
ADAIR, LISA AKA
TARASEVICH, LISA
LPN 4/20/1961 206 LAKEHURST AVENUE,
APT. B
NATIONAL PARK NJ 08063 SUSPENSION 9/19/2002
ADAMS, AMELIA CHHA 9/26/1994 132 OAKMONT ROAD CLEMENTON NJ 08021 DISQUALIFICATION 1/31/2017
ADAMS, ANTOINETTE CHHA 12/29/1976 1604 SEWALL AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 1/31/2017
ADAMS, JAIME L. CHHA 4/15/1976 911 W. HAND AVENUE CAPE MAY CT. HS NJ 08210 SUSPENSION 6/19/2003
ADAMSHICK, WILLIAM RPH 10/9/1960 1871842575 2516 HURRY RD. FORKED RIVER NJ 08731 SUSPENSION 7/14/2005 3/21/2012
ADDIS, DAVID J. MD 8/10/1944 1770656068 334 FARNSWORTH AVENUE BORDENTOWN NJ 08505 DEBARMENT 1/20/2015 PERMANENT
ADES, ALBERT MD 1/11/1955 1912069394 3 MARKHAM CIRCLE ENGLEWOOD NJ 07631 DEBARMENT 5/16/2016
ADES, ALBERT MD 1/11/1955 1912069394 PO BOX 779800 MAIMI FL 33177 DISQUALIFICATION 12/12/2016
ADES, ALBERT (DR.'S
OFFICE)
1447560867 129 MADISON AVENUE CRESSKILL NJ 07626 DISQUALIFICATION 6/16/2017
ADISSON, LECLERC MD 8/14/1946 1482 SW 150TH TERRACE SUNRISE FL 33326 DISQUALIFICATION 7/20/2007 PERMANENT
ADISSON, LUNIC CHHA 11/29/1971 14 WALTER PLACE #1 IRVINGTON NJ 07111 DISQUALIFICATION 3/14/2008
ADOLPHE, NAOMIE CHHA 8/24/1982 410 FISHER AVENUE NEPTUNE NJ 07753 DISQUALIFICATION 2/20/2017
ADU-BOAHENE, KWABENA CHHA 2/19/1975 3 AUGUSTA DRIVE LITTLE EGG HARBOR NJ 08087 DISQUALIFICATION 1/23/2018
AFRIYIE, BRIGHT CHHA 6/20/1994 317 W. RUNYON STREET, 3L NEWARK NJ 07108 DISQUALIFICATION 1/23/2018
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
3
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
AGARWAL, SHASHI K. MD 6/15/1952 1558416099 198 CENTRAL AVENUE 1ST FL EAST ORANGE NJ 07018 SUSPENSION 10/22/2012
AGARWAL, SHASHI K. MD 6/15/1952 1558416099 FCI SCHUYLKILL, PO BOX 759 MINERSVILLE PA 17954 DEBARMENT 2/28/2014
AGRAWAL, PANKAJ MD 9/16/1949 1962661215 3 E. MEADOWBROOK CIRCLE SICKLERVILLE NJ 08081 DISQUALIFICATION 3/11/2006
AGRESTA JR., RUDOLPH G. MD 8/18/1954 PO BOX 7450 TRENTON NJ 08628 SUSPENSION 2/19/2004
AGRESTI, ROBERT MD 4/11/1957 1619155710 15 BARBERRY WAY ESSEX FALLS NJ 07021 DISQUALIFICATION 6/26/2018
AGUIAR, SANDRA 2/3/1967 605 KNICKERBOCKER RD. TENAFLY NJ 07670 DISQUALIFICATION 6/18/2009
AGUILAR, RUBEN RPH 9/21/1962 16 GOLDENROD DRIVE BELLE MEAD NJ 08502 SUSPENSION 7/20/2010
AGUIRRE-MEDRANO,
CANDIDA
10/24/1915 40 FERRY STREET NEWARK NJ 07105 DEBARMENT 7/12/1999
AGYEMANG, JOHN RPH 2/18/1969 1487934626 153 BLUE MEADOW LANE SICKLERVILLE NJ 08081 DISQUALIFICATION 12/28/2016
AGYEMANG, KWADWO RPH 3/8/1958 1154713394 94 MARKET STREET NEWARK NJ 07102 DEBARMENT 8/25/2003 6/3/2015
AHLAWAT, RANVIR MD 7/21/1964 1447204615 2204 ARVELL STREET TOMS RIVER NJ 08755 DEBARMENT 12/19/2016
AHMAD, ABADULLAH 4/3/1984 280 LOUIS MARIN BLVD #15 JERSEY CITY NJ 07302 SUSPENSION 2/19/2009
AHMAD, FAROOQ RPH 10/1/1943 1659605590 300 EAST HALSEY RD. PARSIPPANY NJ 07054 SUSPENSION 11/8/1994
AHMAD, NAEEM S 682 BERGEN AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 9/15/1983
AHMAD, NAVEED MD 1/3/1950 1669412946 48 SUYDAM ROAD SOMERSET NJ 08873 DISQUALIFICATION 9/29/2016 PERMANENT
AHMAD, NAVEED MD 1/3/1950 1669412946 48 SUYDAM ROAD SOMERSET NJ 08873 DISQUALIFICATION 12/20/2016 PERMANENT
AHMED, AMIR E. 1/1/1962 7-11 TONNELLE AVENUE-2MN JERSEY CITY NJ 07306 SUSPENSION 5/30/1997
AHMED, KHALID H. 2/6/1963 PO BOX 930 NEW YORK NY 10013 DISQUALIFICATION 3/26/1994
AHMED, MOHAMED G. PHARM
TECH
7/14/1989 5 WESTOVER TERRACE WEST ORANGE NJ 07052 DISQUALIFICATION 8/20/2010
AIRD, EILEEN, B. 6/28/1950 295 GRANDVIEW CIRCLE RIDGEWOOD NJ 07450 SUSPENSION 4/20/2003
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
4
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
AKANDE, EZEKIEL MD 1/15/1959 1003859885 300 HAIL KNOB ROAD,
#290828
SOMERSET KY 42503 DISQUALIFICATION 9/20/2017
AKHMEDOV, KHUSEN 8/1/1990 SCI GRATERFORD, ME9849,
PO BOX 244
GRATERFORD PA 19426 DISQUALIFICATION 11/20/2015
AKHTAR, NADEEM RPH 12/16/1959 1063695963 15 GRIST MILL LANE UPPER SADDLE
RIVER
NJ 07458 DEBARMENT 1/20/2012
AKHTAR, NADEEM RPH 12/16/1959 1063695963 15 GRIST MILL LANE UPPER SADDLE
RIVER
NJ 07458 DISQUALIFICATION 9/20/2012
AKINBILE, MORUFU O. RN 5/1/1966 419 E. MOOREHAVEN DRIVE CARSON CA 90746 DISQUALIFICATION 8/20/2010
AL SALIHI, FAROUK MD 7/1/1934 1720158025 1810 JOHN F. KENNEDY BLVD JERSEY CITY NJ 07305 SUSPENSION 5/1/2011
AL SALIHI, FAROUK MD 7/1/1934 1720158025 1810 JOHN F. KENNEDY BLVD JERSEY CITY NJ 07305 DEBARMENT 1/9/2015
ALAMEEN, ALWALEED TEMPT
TRANS
5/16/1968 238 MAIN STREET HACKENSACK NJ 07601 SUSPENSION 7/18/1995
ALAN, DAVID OD 7/26/1946 1225012073 203 NORTH REDWOOD ST MASONTOWN PA 15461 DISQUALIFICATION 11/20/2015
ALBERS, HENRY J. EMT 8/22/1944 3 QUEEN STREET PARSIPPANY NJ 07054 DISQUALIFICATION 1/9/1996
ALBINO, ETHAN RN 3/4/1989 224 FERN AVENUE HADDON
TOWNSHIP
NJ 08108 DISQUALIFICATION 9/7/2017
ALCAIDE, KELLEY LPN 2/4/1969 716 RIVER RD. SOMERVILLE NJ 08844 SUSPENSION 2/20/2002
ALEXANDER, EDWARD J. MD 6/4/1955 8001 CASTOR AVENUE, STE.
326
PHILADELPHIA PA 19152 DEBARMENT 8/8/2000
ALEXANDER, JULIE B. RPH 8/20/1972 1525 DOGWOOD DRIVE CHERRY HILL NJ 08003 SUSPENSION 5/19/2005
ALFONSO, NORMA CHHA 5/21/1948 144 SUMMIT STREET ENGLEWOOD NJ 07631 SUSPENSION 8/19/1997
AL-GHRAOUI, FADI MD 4/9/1955 PO BOX 23429 FORT LAUDERDALE FL 33307 DISQUALIFICATION 11/18/2004
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
5
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ALI, HANIFAH CHHA 12/3/1990 1216 FALCON DRIVE ABSECON NJ 08201 DISQUALIFICATION 2/20/2017
ALI, MOHAMED MD 4/18/1954 64 BEVAN STREET JERSEY CITY NJ 07306 DISQUALIFICATION 5/31/1994
ALI, SAQIB 3/14/1954 MDC BROOKLYN, PO BOX
3290
BROOKLYN NY 11232 DEBARMENT 5/20/2012
ALI, TARK TARK
TRANS
566 BLOOMFIELD AVENUE BLOOMFIELD NJ 07306 DISQUALIFICATION 5/10/1999
ALLEN, ADINA CHHA 8/21/1979 219 PINEBROOK DRIVE MANTUA NJ 08051 DISQUALIFICATION 5/22/2017
ALLEN, KENNYATTA G. 1/14/1976 148 CORNERSTONE PLACE WHITEHALL PA 18052 DISQUALIFICATION 3/14/2008
ALLEN-BROGAN, MELANIE
A.
8/1/1984 135 WILD OAKS COURT LITTLE EGG HARBOR NJ 08701 SUSPENSION 3/5/2008
ALLIED CLINICAL LAB, INC. 5199 S. GREEN STREET SALT LAKE CITY UT 84123 DISQUALIFICATION 6/18/1997
ALLIED CLINICAL LAB, INC. 863 MCCALLIE AVENUE CHATTANOOGA TN DISQUALIFICATION 6/18/1997
ALLRED, ELLEN ANNE RN 3/11/1975 571 FERNWOOD LANE FAIRLESS HILLS PA 19030 DISQUALIFICATION 11/20/2015
ALLSTATE AMBULANCE
CORPORATION
PO BOX 1011 UNION NJ 07083 DISQUALIFICATION 4/3/2000
ALPERIN, MARTIN MD 8/20/1927 28 RIVERSIDE AVENUE RED BANK NJ 07701 DEBARMENT 6/19/2000
ALPERT, PERRY DDS 8/4/1941 1952668782 560 NEWARK AVENUE ELIZABETH NJ 07208 SUSPENSION 10/2/1995
ALSTON, SHERRELLE 12/11/1970 NORTH 52ND STREET PHILADELPHIA PA 19139 DEBARMENT 10/9/2007
ALVIS, SANDRA CHHA 5/29/1955 1421 HOLLINSHED AVENUE PENNSAUKEN NJ 08110 SUSPENSION 5/19/2005
ALY, ABUBAKR CRESCEN
T TRANS
5/26/1955 24 BRANFORD PLACE NEWARK NJ 07102 DISQUALIFICATION 3/11/2004
ALY, AHMED F. RPH 4/16/1974 1030 LIBERTY AVENUE UNION NJ 07083 SUSPENSION 8/17/2007
ALY, WAEL 10/30/1966 1137 MAIN AVENUE CLIFTON NJ 07011 SUSPENSION 5/30/2000
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
6
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
AMABILE, JOHN C. OD 4/23/1962 HIGHWAY #35 & 3RD AVENUE OCEAN NJ 07712 DISQUALIFICATION 6/30/2002
AMAKER, PHYLLIS CHHA 3/25/1960 475 LIVINGSTON DRIVE EAST WINDSOR NJ 08520 DISQUALIFICATION 1/31/2017
AMANKWAH, VINCENTIA 11/4/1978 8 MAPLES AVENUE CLIFFWOOD NJ 07721 DEBARMENT 5/1/2016
AMANKWAH, VINCENTIA 11/4/1978 8 MAPLES AVENUE CLIFFWOOD NJ 07721 DISQUALIFICATION 3/28/2017
AMATO, NICOLA DC 3/1/1963 1366941627 3 MULLIGAN DRIVE FLANDERS NJ 07836 SUSPENSION 6/20/2005
AMATO, STEVEN P. DC 8/1/1955 30151 FISH ROCK RD. YORKVILLE CA 95494 DISQUALIFICATION 10/20/2009
AMATO, VANESSA A. AKA
VANESSA A. NOWINSKI
RN 3/21/1977 65 LOCUST AVENUE N. ARLINGTON NJ 07031 SUSPENSION 9/19/2003
AMBROSE, DEAN A. DO 6/18/1957 1598832560 119 NORTH CENTRE STREET MERCHANTVILLE NJ 08109 DEBARMENT 2/1/2002
AMENYITOR, APEAFA CHHA 3/9/1987 14 MARSHALL STREET, APT.
14W
IRVINGTON NJ 07111 DISQUALIFICATION 2/20/2017
AMERICAN EXPRESS LOAN,
INC.
1386883239 13420 DAMAR DRIVE, SUITE C PHILADELPHIA PA 19116 DISQUALIFICATION 11/20/2015
AMERICAN MED. TECH.,
INC.
1072 MADISON AVENUE LAKEWOOD NJ SUSPENSION 4/14/1999
AMERICAN MEDICAL
EXPRESS AMBULANCE, LLC.
1205071883 PO BOX 3093 WARMINSTER PA 18974 DISQUALIFICATION 11/20/2015
AMIN, PRISCILLA CHHA 6/18/1990 133 ATLANTIC STREET HACKENSACK NJ 07601 DEBARMENT 10/23/2017
AMPARO, VIANNE CHHA 10/2/1982 710 EAST 18TH STREET PATERSON NJ 07501 DISQUALIFICATION 1/31/2017
AMPOFO, TWUMASI 6/3/1968 12 MARSHALL STREET #7W IRVINGTON NJ 07111 SUSPENSION 2/1/2008
AMPOFO, TWUMASI 6/3/1968 12 MARSHALL STREET #7W IRVINGTON NJ 07111 DISQUALIFICATION 3/30/2009
ANAND, SUBINA DDS 8/30/1967 1982781589 17 GROVERS MILL RD. PLAINSBORO NJ 08536 DISQUALIFICATION 12/20/2012
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
7
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ANAND, SUBINA DDS 8/30/1967 1982781589 17 GROVERS MILL RD. PLAINSBORO NJ 08536 DISQUALIFICATION 4/17/2012
ANDAS PHARMACEUTICAL
SUPPLY CORP.
592 PALISADE AVENUE TEANECK NJ 07666 DISQUALIFICATION 5/20/2018
ANDERSON, CHARMAINE RN 10/16/1973 95 FARRAGUT ROAD NORTH PLAINFIELD NJ 07062 DISQUALIFICATION 6/28/2017
ANDERSON, DAVID RN 4/3/1951 519 HOBART AVENUE TRENTON NJ 08629 SUSPENSION 10/20/2003
ANDERSON, FRANCINE CHHA 7/6/1967 901 PRINCETON AVENUE LAKEWOOD NJ 08701 DISQUALIFICATION 2/12/2018
ANDERSON, JOHN P. MD 8/25/1926 362 S. LAUREL STREET WAYNEBORO VA 22980 SUSPENSION 1/20/1999
ANDERSON, NICOLE RN 8/27/1986 1801 HUNTINTON MEWS CLEMONTON NJ 08021 DISQUALIFICATION 8/28/2017
ANDRADE, GLORIA LCSW/LC
ADC
9/18/1962 1992804850 679 GRANT TERRACE TEANECK NJ 07666 SUSPENSION 6/18/2018
ANDUJAR, EDWARD MD 12/23/1955 516 E. WOOD STREET VINELAND NJ 07410 DISQUALIFICATION 1/20/2006
ANELLO, ALLYSON PHARM
TECH
9/30/1984 708 FOX HILL DRIVE DOVER NJ 07801 DISQUALIFICATION 2/5/2018 PERMANENT
ANGEL, CHRISTINA CHHA 5/9/1989 145 PRESIDENTIAL
BOULEVARD, APT. 16J
PATERSON NJ 07522 DISQUALIFICATION 2/20/2017
ANGELES, KATHERINE MD 4/6/1958 191 ROUTE 37 WEST TOMS RIVER NJ 08755 DEBARMENT 6/23/1995 DECEASED
ANGELO, JOSEPH 3/9/1949 34 STONEHEDGE RD. LINCROFT NJ 07738 DISQUALIFICATION 4/27/1993
ANODIDE, PAUL A. DDS 2/4/1956 1841317625 23 BLUE DEVIL LANE TRENTON NJ 08619 DISQUALIFICATION 2/3/2006
ANTHONY, QUINT LPN 4/7/1956 900 BARNEGAT BLVD. N #908 BARNEGAT NJ 08005 DISQUALIFICATION 6/5/2017
ANTONE, JULIE LCSW 8/9/1980 366 CAMBRIDGE DRIVE RAMSEY NJ 07446 DEBARMENT 2/20/2013
APONTE, DENNIS MD 9/23/1966 1053458018 MDC BROOKLYN, PO BOX
329002
BROOKLYN NY 11232 DISQUALIFICATION 5/20/2015
AQUILANTE, JOHN C. RPH 8/13/1946 27 ROCKLEDGE PLACE CEDAR GROVE NJ 07009 DISQUALIFICATION 9/23/1983
ARDAN, MARGO RN 8/5/1963 161 CONAWAGA TRAIL MEDFORD NJ 08055 DISQUALIFICATION 6/28/2017
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
8
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ARDEHALI, MOHAMMAD MD 12/19/1944 193 ELWOOD AVENUE NEWARK NJ 07104 SUSPENSION 2/20/2001
ARGUETA, ALVARO PSYCH 4/13/1942 1194851618 9408 BIG VIEW DRIVE AUSTIN TX 78730 DISQUALIFICATION 7/22/2017 PERMANENT
ARGUETA, EDWARD A. CNA 4/13/1972 604 N. BAYVIEW AVENUE SEASIDE PARK NJ 08752 SUSPENSION 4/8/1999
ARGUETA, EDWARD A. CNA 4/13/1972 604 N. BAYVIEW AVENUE SEASIDE PARK NJ 08752 SUSPENSION 9/13/1999
ARIF, MOHAMMED 4/5/1965 147-14 14TH AVENUE WHITESTONE NY 11375 DISQUALIFICATION 12/1/1998
ARMBRISTER, KATIMA CHHA 4/12/1973 301 BELMAR AVENUE NEPTUNE NJ 07753 DISQUALIFICATION 2/20/2017
ARNESON, VICTORIA RN 4/1/1969 42 HOLLY STREET CRANFORD NJ 07016 SUSPENSION 9/19/2003
AROWOSAYE, EMILY RN 5/12/1967 24 CUNNINGHAM DRIVE WEST ORANGE NJ 07052 DISQUALIFICATION 7/31/2010
AROWOSAYE, EMILY RN 5/12/1967 24 CUNNINGHAM DRIVE WEST ORANGE NJ 07052 DEBARMENT 5/20/2012
AROWOSAYE, ISAAC 10/8/1956 24 CUNNINGHAM DRIVE WEST ORANGE NJ 07052 DEBARMENT 3/30/2010
AROWOSAYE, ISAAC 10/8/1956 24 CUNNINGHAM DRIVE WEST ORANGE NJ 07052 DEBARMENT 7/4/2014
ASHOKAN, ANNAMALAI MD 7/6/1953 7 ROCKLEDGE DRIVE SUFFERN NY 10901 DEBARMENT 5/1/2004
ASKANAZI, JEFFREY MD 3/23/1951 2322 OLDE FARM LANE HUDSON OH 44236 DEBARMENT 7/19/1999
ASTON, ALEXIA L. LPN 2/12/1980 15 PRIMROSE LANE, APT. 3 DELRAN NJ 08075 DISQUALIFICATION 6/18/2009
ATIENZA, CESAR P. MD 12/12/1943 1164491494 56 COLD INDIAN SPRING RD OCEAN NJ 07712 DISQUALIFICATION 8/6/1991
AUFSEESER, LESLIE DPM 10/21/1948 1164410742 11 MEADOWS LANE WAYSIDE NJ 07712 DEBARMENT 2/12/2018
AUSTIN, BRITTANY CHHA 11/11/1992 420 N. SOUTH CAROLINA
AVENUE
ATLANTIC CITY NJ 08401 DISQUALIFICATION 6/6/2018
AUSTIN, DONALD P 3/3/1960 31 MADISON AVENUE MONTCLAIR NJ 07042 DISQUALIFICATION 6/1/1993
AUSTIN, NIDERIA CHHA 8/5/1994 822 GALINDEZ COURT CAMDEN NJ 08102 DISQUALIFICATION 12/15/2017
AVILES, REBECCA CHHA 2/6/1988 67 MILL ROAD LEVITTOWN PA 19057 DISQUALIFICATION 2/20/2017
AVON PHARMACY 300 MAIN STREET AVON NJ 07717 SUSPENSION 2/5/2003
AYALA, ANDRES 7/20/1954 33 MADISON AVENUE CHERRY HILL NJ 08002 SUSPENSION 9/11/2017
AZAM, CHOWDHURY F. MD 7/1/1954 1922053792 38 ORIOLE DRIVE HACKETTSTOWN NJ 07840 DEBARMENT 2/1/1999 6/30/2015
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
9
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
AZAM, CHOWDHURY F. MD 7/1/1954 1922053792 30 DUNSTON LANE MONMOUTH
JUNCTION
NJ 08852 DEBARMENT 10/26/2016
AZIZ-DURRANI, MUMLIKAT 8/14/1948 328 SIP AVENUE JERSEY CITY NJ 07306 SUSPENSION 9/19/2002
AZU, PHILIP N. RPH 3/10/1957 2836 DEBRA WAY UNION NJ 07083 DISQUALIFICATION 5/20/1999
AZU, PHILIP N. RPH 3/10/1957 1094 CLINTON AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 4/19/2001
BABARIA, ASHOKKUMAR MD 2/23/1950 1538100599 FCI FORT DIX, PO BOX 2000 FORT DIX NJ 08640 DISQUALIFICATION 11/4/2014
BABARIA, ASHOKKUMAR R. MD 2/23/1950 1538100599 208 QUAKERBRIDGE COURT MOORESTOWN NJ 08057 SUSPENSION 1/10/2012
BABARIA, ASHOKKUMAR R. MD 2/23/1950 1538100599 5756 HARTFIELD/POINTVILLE FORT DIX NJ 08640 DISQUALIFICATION 2/28/2015
BACSENKO, JENNIFER PHARM
TECH
3/18/1976 103 STATE STREET LINWOOD NJ 08221 SUSPENSION 1/20/2011
BADAWY, BADAWY MD 12/27/1962 1679615553 2738 JOHN F. KENNEDY BLVD.
1ST FL
JERSEY CITY NJ 07306 DISQUALIFICATION 2/11/2016
BADAWY, BADAWY MD 12/27/1962 1679615553 2738 KENNEDY BLVD. 1ST FL JERSEY CITY NJ 07306 SUSPENSION 3/25/2013
BADO, JEFFREY DO 8/27/1955 1801908173 1615 ASHBOURNE RD. ELKINS PARK PA 19027 DISQUALIFICATION 11/20/2015
BADO, JEFFREY #71927-
066
DO 8/27/1955 1801908173 FDC PHILADELPHIA, PO BOX
562
PHILADELPHIA PA 19105 DISQUALIFICATION 11/20/2017
BADUINI, JOLIE RN 6/26/1989 1300 32ND AVENUE SW, APT.
307
MINOT ND 58701 DISQUALIFICATION 5/20/2015
BAER, MICHAEL L. DC 6/12/1953 1053654616 BAYSIDE STATE PRISON LEESBURG NJ 08327 SUSPENSION 9/20/2004
BAEZ, ANNA DDS 3/6/1961 911 VILLAGE DRIVE SOMERSET NJ 08873 SUSPENSION 3/20/2002
BAFFOWAAH, ZIBORAH 12/15/1970 4345 DIAMOND DRIVE SAINT PAUL MN 55122 DISQUALIFICATION 2/20/2015
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
10
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BAGDASAROVA, ANGELICA RN 7/17/1964 11981 AUDUBON AVENUE PHILADELPHIA PA 19116 DISQUALIFICATION 11/20/2015
BAH, HUSAINATU 9/9/1988 2510 BIRCHWOOD COURT NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 1/15/2016
BAH, HUSAINATU 9/9/1988 2510 BIRCHWOOD COURT NORTH BRUNSWICK NJ 8902 DISQUALIFICATION 11/28/2013
BAHNSON, WILLIAM F. MD 11/12/1927 28 HIGH STREET TREENFIELD MA 01301 DISQUALIFICATION 9/2/1988 DECEASED
BAILEY, FREDERICK DDS 1/29/1960 1205048410 41 WEST GLEN ROAD DENVILLE NJ 07834 DISQUALIFICATION 9/29/2016
BAIRD, DAVID B. MD 5/11/1937 4107 MERCHANT SQ. PLACE LANSDALE PA 19446 SUSPENSION 5/20/2004
BAJAKIAN, BRYAN DC 6/22/1959 1679618094 3105 STOWE LANE MAHWAH NJ 07430 DISQUALIFICATION 10/18/2010
BAJWA, LATIF AHMAD ACCUPU
NCTURIST
5/7/1948 PO BOX 633 LANGHORNE PA 19047 SUSPENSION 2/9/2009
BAKER, SCOTT CNA 3/31/1972 215 BURLINGTON RD. SOUTH BRIDGETON NJ 08302 DISQUALIFICATION 5/24/2002
BALLERAS, ALFREDO B. RPH 1/21/1972 1 VISTA DRIVE MOUNT OLIVE NJ 07836 DISQUALIFICATION 9/14/2010 9/13/2013
BAMDAD, BABAK RPH 8/21/1968 1285950642 2 SOUTH GATE RD., APT. 736 GREAT NECK NY 11023 DISQUALIFICATION 7/26/2011
BAMDAD, BABAK RPH 8/21/1968 1285950642 333 RIVER STREET HOBOKEN NJ 07030 DEBARMENT 6/1/2010
BAMGBOYE, PATRICK DDS 1/1/1948 1720175508 358 MEISEL AVENUE SPRINGFIELD NJ 07081 DEBARMENT 11/7/2012
BANDY, ANHUAR 5/28/1963 141 CRINE ROAD COLTS NECK NJ 07722 DISQUALIFICATION 6/20/2018
BANDY, KARIM 2/27/1962 141 CRINE ROAD COLTS NECK NJ 07722 DISQUALIFICATION 6/20/2018
BANGOURA, ALPHA 1/1/1974 200 EXECUTIVE DRIVE WEST ORANGE NJ 07050 SUSPENSION 3/22/2006
BANKA, VIDYA MD 3/5/1941 1588659965 237 STACEY ROAD PENN VALLEY PA 19072 DISQUALIFICATION 3/19/2018
BANKS, KENNETH 5/13/1934 640 PINE STREET CAMDEN NJ 08103 DEBARMENT 8/14/2003
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
11
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BAPTISTE, STANLEY CHHA 1/17/1992 401 WEST VIRGINIA AVENUE,
APT B-16
NEPTINE NJ 07753 DISQUALIFICATION 4/19/2018
BARAHONA, RONY 8/9/1962 549 SUMMIT AVENUE MAPLEWOOD NJ 07040 DEBARMENT 3/26/2013
BARAN-DICRISCIO,
LORRAINE
CHHA 12/3/1939 309 IRIS RD. CHERRY HILL NJ 08620 SUSPENSION 3/20/2002
BARAQUE, IVAN DARIO MD 1/31/1950 1811059967 4 WOODCREST COURT WEST NYACK NY 10994 DISQUALIFICATION 2/20/2015
BARASCH, MILTON RPH 1/15/1935 12 IVY WAY ABERDEEN NJ 07747 DEBARMENT 8/3/2000
BARATTI, CARMEN DO 7/16/1934 150 KIRKBRIDGE RD. VOORHEES NJ 08043 SUSPENSION 9/4/1997
BARBA, FIDELIS MD 4/25/1948 2 POWDER HILL SADDLE RIVER NJ 07458 DISQUALIFICATION 10/11/2000
BARBER-HINSON, CONNIE 1/4/1958 7011 SHADOW RUN SAN ANTONIO TX 78250 SUSPENSION 4/20/2011
BARBERS-WEBER,
JENNIFER
12/10/1969 8 ELKRIDGE PARKWAY MANALAPAN NJ 07726 SUSPENSION 11/5/2009
BARDEN, BRENDA RN 7/5/1955 19 INTERVALE RD. SALEM MA 01970 DISQUALIFICATION 12/20/2012
BARDO, MANUEL 6/19/1944 11756 SW 14TH TERRACE MIAMI FL SUSPENSION 8/19/2004
BARET, MICHELLE CHHA 6/4/1989 135 MARINA DRIVE EDISON NJ 06076 DISQUALIFICATION 2/8/2017
BARGE, NICHOLAS 6/7/1989 716 NAUTILUS STREET FORKED RIVER NJ 08731 DEBARMENT 3/16/2011
BARI, ABDUL 8/2/1954 264 PROSPECT STREET NUTLEY NJ 07110 DISQUALIFICATION 6/19/2009
BARIEXCA, CARLA LPN 12/14/1974 107 DAYTON STREET TRENTON NJ 08610 SUSPENSION 8/20/2006
BARNA, ARLENE RN 2/12/1936 205 KRAFT AVENUE OAKLYN NJ 08107 SUSPENSION 9/19/2003
BARNWELL, LATANYA 1/23/1984 1048 PENNINGTON RD. EWING NJ 08618 DEBARMENT 9/16/2011 9/17/2014
BARON, MICHAEL B. MD 2/27/1947 SE 1256 BISHOP BLVD., STE1 PULMAN WA 99163 DEBARMENT 9/11/2000
BARONE, THOMAS DO 1/22/1969 1780898965 255 17TH STREET, SUITE 601 PHILADELPHIA PA 19103 DISQUALIFICATION 11/20/2015
BARROUS, FELIPE EMT 9/6/1988 40 KNOLL TERRACE HAZLET NJ 07730 DISQUALIFICATION 2/28/2015
BARTLOW, BRIAN 3/3/1960 551 PARKWOOD AVENUE TOMS RIVER NJ 08753 SUSPENSION 7/17/2003
BASBUS, VIICTOR M. MD 7/18/1944 1811098858 33 5TH AVENUE, APT. 1B NEW YORK NY 10003 DEBARMENT 2/6/2009
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
12
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BASSO, NICHOLAS V. MD 12/13/1945 7665 MAPLE AVENUE PENNSAUKEN NJ 08109 DEBARMENT 2/1/2000
BATARSEH, BASEL MD 5/12/1960 1063602696/
1891803318
620 FAIRLAWN AVENUE GLEN ROCK NJ 07410 DEBARMENT 12/31/2017
BATEMAN, PAMELA LPN 6/19/1956 91 CHESTNUT STREET SALEM NJ 08079 SUSPENSION 7/21/2008
BATES, NANCY M. DO 9/10/1955 1043435209 38 PALSA AVENUE ELMWOOD PARK NJ 07407 DEBARMENT 4/3/2001
BATTLE, TIFANY CHHA 5/13/1981 393 IRVINE TURNER
BOULEVARD, APT. 4D
NEWARK NJ 07108 DISQUALIFICATION 2/20/2017
BAUBLITZ, CARRIE RN 6/2/1973 80 CONEWAGO DRIVE HANOVER PA 17331 DISQUALIFICATION 12/29/2015
BAUTISTA, FILOMENA CHHA 7/31/1946 133 PAMRAPO AVENUE #1 JERSEY CITY NJ 7305 DISQUALIFICATION 7/14/2017
BAXTER, LOUIS E. MD 3/17/1952 1962527051 2 MANCHESTER COURT COLUMBUS NJ 08022 DISQUALIFICATION 10/26/1983 4/2/2013
BEACHUM-THOMPSON,
AMY
CHHA 1/11/1992 201 WEBSTER STREET WOODBINE NJ 08270 DISQUALIFICATION 1/17/2018 8/20/2018
BEALS, PAUL V. MD 4/15/1943 1427175652 4120 WESTFIELD AVENUE PENNSAUKEN NJ 08110 SUSPENSION 6/24/2014
BECK, ALLAN G. MD 2/5/1944 1833 ARROWHEAD DRIVE WATERFORD NJ 08089 SUSPENSION 2/20/2001
BECKETT, DONALD DPM 12/28/1948 1871692285 10144 DEERCLIFF DRIVE TAMPA FL 33647 DISQUALIFICATION 11/4/2005
BECKFORD, AUDREY L. 6/1/1968 566 NORTH MAPLE AVENUE EAST ORANGE NJ 07017 SUSPENSION 1/20/2002
BEDRICK, BERNARD A. 300 EAST 5 6TH STREET NEW YORK NY 10022 DISQUALIFICATION 6/1/1993
BEECHER, GEORGE MD 9/26/1940 1073574059 137 EVERGREEN AVENUE NW PROVIDENCE NJ 07974 SUSPENSION 6/8/2016
BEHRMAN, EDWARD DO 10/9/1932 520 HAMBURG TURNPIKE WAYNE NJ 07470 DISQUALIFICATION 12/1/1998
BEIRNE, MARY F. MD 6/25/1949 1881782662 75 ABE VORHEES AVENUE MANASQUAN NJ 08736 DISQUALIFICATION 7/19/2001 5/16/2011
BEKIER, JACQUELYN CHHA 10/11/1993 518 LAKE TERRACE BRADLEY BEACH NJ 07720 DISQUALIFICATION 1/31/2017
BELIAEV, KIRA CHHA 12/12/1957 108 36TH STREET UNION CITY NJ 07087 DISQUALIFICATION 2/20/2017
BELKOFF, MEYER DO 9/9/1921 29 ELMORA AVENUE ELIZABETH NJ 07202 DEBARMENT 7/17/1998 DECEASED
BELL, BEANA 1/30/1982 9926 HALDEMAN AVENUE PHILADELPHIA PA 19115 DISQUALIFICATION 11/20/2015
BELL, KIMBERLY F. RN 11/9/1961 2030 HIGHWAY 35 N. UNIT K ORTLEY BEACH NJ 08735 SUSPENSION 6/20/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
13
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BELL, SHANNON PHARM
TECH
2/23/1979 6591 MILL ROAD EGG HARBOR
TOWNSHIP
NJ 08234 DISQUALIFICATION 5/23/2017
BELLAMY, BERNICE 5/24/1957 1 CRISPIN ROAD LUMBERTON NJ 08060 DEBARMENT 10/20/2004
BELLAMY, HARVEY H&B
TRANS.
9/30/1962 CRAF PO BOX 7450 TRENTON NJ 08625 DISQUALIFICATION 10/20/2004
BELLO, REY N. MD 11/18/1957 1780796409 444 60TH STREET WEST NEW YORK NJ 07093 SUSPENSION 1/31/2011 PERMANENT
BELMAR HOMETOWN
PHARMACY
911 MAIN STREET BELMAR NJ 07719 SUSPENSION 2/5/2003
BELONY, IVELYSE LPN 9/4/1989 131 PARK PLACE, APT. 1 IRVINGTON NJ 07111 DISQUALIFICATION 3/28/2017
BELTZER, BLAIR MD 5/5/1957 1073635421 2025 HAMBURG TURNPIKE WAYNE NJ 07470 DEBARMENT 12/16/2015
BENKO, ALICIA PHARM
TECH
12/27/1986 FCI DANBURY RT 37, #60674-
050
DANBURY CT 06811 DISQUALIFICATION 9/18/2009
BENNETT, SHARON CHHA 9/27/1954 736 EDGEWOOD AVENUE TRENTON NJ 08618 DISQUALIFICATION 1/31/2017
BENNETT-WILLIAMSON,
KATHLEEN
LPN 7/12/1951 75 WALT WHITMAN WAY TRENTON NJ 08690 DISQUALIFICATION 8/27/2001
BENSIMHON, GEORGES MD 2/1/1947 1649234394 1488 SHELBURNE COURT ALLENTOWN PA 18104 DEBARMENT 12/16/2015
BENTLEY, CYNTHIA RN 10/7/1959 220 GILPIN ROAD WILLOW GROVE PA 19090 DISQUALIFICATION 6/15/2018
BERGER, SHELDON H. MD 5/26/1929 1032 ROUTE 34 MATAWAN NJ 07747 DEBARMENT 9/30/2000
BERKELHAMMER, EDWARD MD 12/18/1941 230 W. JERSEY ST. ELIZABETH NJ 07202 DISQUALIFICATION 8/30/1990
BERKS PSYCHIATRY 1104949149 146 SOUTH 5TH STREET READING PA 19602 DISQUALIFICATION 11/20/2015
BERMAN, LARRY R. DDS 12/14/1953 1326191347 308 RARITAN DRIVE HIGHLAND PARK NJ 08904 DISQUALIFICATION 8/24/2010
BERMAN, LARRY R. DDS 12/14/1953 1326191347 308 RARITAN AVENUE HIGHLAND PARK NJ 08904 DISQUALIFICATION 12/20/2012
BERRY, BRADLEY D. MD 4/10/1919 PO BOX 2008 GRUNDY VA 24614 DISQUALIFICATION 6/13/1991
BEST, ALEXANDER C. 3/19/1969 PO BOX 7000 FORT DIX NJ 08640 SUSPENSION 7/20/2005
BETHEA, ALFREDA LPN 5/12/1951 1234 PROSPECT STREET TRENTON NJ 08638 SUSPENSION 10/20/2002
BEUKAS, STEPHEN DMD 9/3/1965 1275677213 27 ROUTE 34 NORTH COLTS NECK NJ 07722 DEBARMENT 3/30/2014
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
14
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BEYNON-SERFASS, LEONOR RN 12/11/1963 18 WILSON AVENUE CLARKS SUMMIT PA 18411 DISQUALIFICATION 11/30/2017
BEZOZA, HOWARD M. MD 9/3/1952 PO BOX 372 SADDLE RIVER NJ 07458 SUSPENSION 7/20/2003
BHATTI, HAMID 10/3/1977 80 MILTON AVENUE, #1522 RAHWAY NJ 07065 DISQUALIFICATION 9/20/2012
BIENSTOCK, DOUGLAS DO 6/27/1966 1831151356 245 DIAMOND BRIDGE
AVENUE
HAWTHORNE NJ 07506 DEBARMENT 12/16/2015
BIENSTOCK, DOUGLAS DO 6/27/1966 1831151356 245 DIAMOND BRIDGE
AVENUE
HAWTHORNE NJ 07506 DISQUALIFICATION 5/12/2016
BILENKIN, ELANA 8/19/1969 242 COMUNITY CIRCLE OLD BRIDGE NJ 08857 DISQUALIFICATION 4/15/1998
BINDER, RANDY RPH 2/19/1953 1972526572 FCI PO BOX 1000 OTISVILLE NY 10963 DISQUALIFICATION 8/20/2015 PERMANENT
BINDER, RANDY RPH 2/19/1953 1972526572 16 WINTER PLACE ABERDEEN NJ 07747 DISQUALIFICATION 9/20/2016 PERMANENT
BIODIAGNOSTICS LAB
SERVICES
1407923568 181 NEW STREET PARSIPPANY NJ 07054 SUSPENSION 1/21/2015
BIONDELLO JR., PHILIP 9/8/1966 41 CONCORD LANE BASKING RIDGE NJ 07920 DISQUALIFICATION 7/20/2017
BIO-SCIENCE LAB, INC. 1000 WOODBRIDGE COURT WOODBRIDGE NJ 07095 DEBARMENT 3/20/2000
BISHARA, GIRGIS MD 12/23/1921 859 BRIGHTON PL. OCEAN CITY NJ 08226 DISQUALIFICATION 1/17/1987
BITTNER, MELISSA C. RN 10/21/1976 436 RIVER DRIVE WESTVILLE NJ 08093 SUSPENSION 1/19/2005
BLACKMAN, NOEL MD 12/18/1947 1720209521 MOSHANNON VALLEY CI, 555
GEO DRIVE
PHILLIPSBURG PA 16866 DISQUALIFICATION 11/30/2017 PERMANENT
BLACKMAN, NOEL MD 12/18/1947 1720209521 MOSHANNON VALLEY CI, 555
GEO DRIVE
PHILLIPSBURG PA 16866 DISQUALIFICATION 3/26/2017 PERMANENT
BLANCO, ALEX DPM 2/21/1972 1881677987 180 LAFAYETTE AVENUEM
APT. 12A
PASSAIC NJ 07055 DISQUALIFICATION 8/24/2017
BLANCO, LAZARO PHARM
TECH
12/26/1990 401 46TH STREET, APT. 5 UNION CITY NJ 07087 DISQUALIFICATION 8/28/2017
BLANTON, MALEEK CHHA 8/13/1992 640 LINE STREET CAMDEN NJ 08103 DISQUALIFICATION 7/14/2017
BLAU, SEYMOUR H. DPM 5/28/1923 36 COLLEGE DRIVE JERSEY CITY NJ 07305 SUSPENSION 11/20/2003
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
15
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BLEIMAN, MICHAEL MD 8/24/1961 1821086463 1100 ROUTE 72 WEST, SUITE
304
MANAHAWKIN NJ 08050 SUSPENSION 1/27/2017 4/27/2017
BLOOMFIELD PHARMACY 154 BLOOMFIELD AVENUE NEWARK NJ 07104 DISQUALIFICATION 1/31/2000
BLOT, EDWARD MD 3/25/1941 274 NORTH CENTER STREET ORANGE NJ 07050 DEBARMENT 7/5/2000
BLUM, NOEL 74 TWIN RIVERS DRIVE EAST WINDSOR NJ 08561 DISQUALIFICATION 6/1/1993
BLY, RODNEY 5/28/1965 4737 FRANKFORD AVE., 3RD
FL
PHILADELPHIA PA 19124 DISQUALIFICATION 11/20/2015
BLYN, CHARLOTTE MD 11/18/1928 1669700910 511 WINDING WAY MERION STATION PA 19066 DISQUALIFICATION 11/20/2015
BMA MEDICAL
LABORATORY
59-07 71ST AVENUE RIDGEWOOD NY 11385 SUSPENSION 10/20/2003
BOADU, JACOB RPH 9/23/1959 EUCLID TERRACE PARSIPPANY NJ 07054 SUSPENSION 8/20/2007
BOAMAH, KWAKU MD 2/4/1957 1154413029 101 HAVEN WAY MORGANVILLE NJ 07751 DEBARMENT 6/7/2017
BOBADILLA, MARIA CHHA 6/2/1969 85 PRESIDENTIAL
BOULEVARD, APT. 2K
PATERSON NJ 07522 DISQUALIFICATION 3/5/2018
BOBRYSHEVA, SVETLANA CHHA 3/8/1961 29 FOREST GARDENS DRIVE MATAWAN NJ 07747 DISQUALIFICATION 9/26/2017
BODINE, DENISE RN 7/5/1964 66 YORK STREET, APT. 12 LAMBERTVILLE NJ 08530 DISQUALIFICATION 5/25/2011
BOEHM, GREGORY MD 6/4/1949 1972678894 26777 LORAIN AVENUE, SUITE
716
NORTH OLMSTEAD PA 44070 DISQUALIFICATION 11/20/2015
BOGUSLAVSKIY, VADIM A & S IC 6/10/1948 1903 MADALINE DRIVE AVENEL NJ 07001 SUSPENSION 12/20/2001
BOGUSLAVSKIY, VADIM A & S IC 6/10/1948 1903 MADALINE DRIVE AVENEL NJ 07001 DISQUALIFICATION 3/25/2002
BOHUSLAWSKY, NINA RN 10/9/1970 PO BOX 4004 CLINTON NJ 08809 DISQUALIFICATION 2/20/2010
BOISVERT, RAYMOND
JOHN
RN 12/8/1961 2701 NW 23 BLVD, APT. 225 GAINESVILLE FL 32605 DISQUALIFICATION 8/20/2015
BOND, CLIFTON MD 9/5/1956 418 JAMESTOWN COURT MT. LAUREL NJ 08054 DISQUALIFICATION 2/21/1992
BONDAR, SOFIYA DDS 8/24/1954 1952355158 2815 COYLE ST. APT. 210 BROOKLYN NY 11235 DISQUALIFICATION 11/18/2011
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
16
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BONETT, OLGA 3/7/1967 5105 N. PARK DRIVE PENNSAUKEN NJ 08109 SUSPENSION 4/29/2003
BONILLA, CLEMY CHHA 4/17/1994 2809 YORKSHIP ROAD CAMDEN NJ 08104 DISQUALIFICATION 2/8/2017
BONNELL, STEPHANIE RN 12/18/1974 165 DEY GROVE RD MONROE NJ 08831 SUSPENSION 2/20/2002
BONSU, ACHIAA CHHA 1/20/1982 1414 BIRCHWOOD COURT NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 7/14/2017
BONSU, KWADWO CHHA 8/5/1988 911 AZALEA DRIVE NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 1/31/2017
BONSU, NANA CHHA 3/4/1985 68 MYRTLE AVENUE IRVINGTON NJ 07111 DEBARMENT 3/6/2018
BOODRAM, VERONA 10/31/1977 134 EVERGREEN PLACE 8TH EAST ORANGE NJ 07018 SUSPENSION 3/22/2006
BOONE, LESLIE RN 10/18/1961 122 SUMMIT AVENUE TRENTON NJ 08628 SUSPENSION 6/20/2002
BORCHARDT, KAREN RN 1/18/1952 4145 MILL CREEK DRIVE N. CHARLESTON SC 29420 SUSPENSION 6/17/2004
BORGES, JOHN MANUEL 4/16/1964 550 BUCKINGHAM DRIVE PISCATAWAY NJ 08854 DISQUALIFICATION 8/20/2010
BORNHOLDT, HAE SUK THERAPIS
T
5/17/1958 PO BOX 1288 MCAFEE NJ 07428 SUSPENSION 9/19/2002
BORNSTEIN, KATHLEEN LPN 12/29/1963 136 73RD STREET NORTH BERGEN NJ 07047 SUSPENSION 2/19/2004
BOROWEC, LAWRENCE W. MD 7/22/1952 202 STOTESBURY AVENUE NEWFIELD NJ 08344 DISQUALIFICATION 12/1/1998
BOROWEC, LAWRENCE W. MD 7/22/1952 202 STATESBURG AVENUE NEWFIELD NJ 08344 SUSPENSION 11/18/1997
BORRELLI, HENRY DPM 5/22/1958 1902839830 49 PROSPECT STREET LITTLE FALLS NJ 07424 DEBARMENT 4/6/2010 10/27/2017
BORTZ, AMANDA PHARM
TECH
1/25/1985 13 SWEET BRIAR DRIVE SICKLERVILLE NJ 08081 DISQUALIFICATION 11/21/2016 4/5/2018
BOSTICK, MICHELLE CHHA 6/16/1962 87 TILLINGHAST STREET NEWARK NJ 07108 DISQUALIFICATION 2/20/2017
BOTTENBLEY, CECIL J. DMD 6/6/1950 16 FIRESIDE CT. WILLINGBORO NJ 08046 DISQUALIFICATION 4/9/1987
BOUCHE, JASON 7/16/1984 6641 E. MEADOWLARK LANE PARADISE VALLEY AZ 85253 DISQUALIFICATION 5/20/2012
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
17
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BOULOS-PLUDOWSKI,
GEORGEANN
RPH 1/20/1958 493 RINGWOOD AVENUE PHILLIPSBURG NJ 08865 SUSPENSION 5/19/2005 3/11/2013
BOWICK, JUDY C. CHHA 9/1/1951 1503 BOND STREET ASBURY PARK NJ 07712 SUSPENSION 8/20/2002
BOYD, DARRYL 1/27/1960 PO BOX 38, FCI FORT DIX NJ 08640 DISQUALIFICATION 7/18/2002
BOYKIN, ASHLEE CHHA 5/9/1984 602 HARBOR LANE SICKLERVILLE NJ 08081 DEBARMENT 3/6/2018
BOYKINS, TAMIKA CHHA 5/17/1989 235 ABLETT VILLAGE CAMDEN NJ 08105 DEBARMENT 5/16/2018
BRABHAM, THEODORE J. 9/10/1951 14 HAZARD STREET ELIZABETH NJ 07208 DISQUALIFICATION 12/20/2001
BRACEWORKS PROF
ORTHODONTIST
288 HIGHWAY 35 SOUTH EATONTOWN NJ 07724 SUSPENSION 8/20/2003
BRACUTO, ANNMARIE RN 3/20/1962 1319 ST. GEORGE AVENUE RAHWAY NJ 07065 DISQUALIFICATION 9/12/2016
BRADLEY, EARL B. MD 5/10/1953 1669414553 1181 PADDOCK RD. SMYRNA DE 19977 DISQUALIFICATION 10/20/2012
BRANDT, DOUGLAS A. 9/7/1959 5 HOWARD STREET VERONA NJ 07044 DISQUALIFICATION 2/20/2011
BRANDT, HERBERT L. RPH 10/15/1932 6 DEVONSHIRE DRIVE RANDOLPH NJ 07689 DISQUALIFICATION 2/20/2011
BRANDT, JEFFREY M. 5/13/1957 24 CRESTVIEW LANE MOUNT
ARLINGTON
NJ 07856 DISQUALIFICATION 11/17/2011
BRAUNSTEIN, MOSES 2404 BRONX PARKWAY BRONX NY 10458 DISQUALIFICATION 6/1/1993
BRAVER, ALEXANDER MD 10/18/1950 1811098650 127 CROAK AVENUE STATEN ISLAND NY 10314 DISQUALIFICATION 7/20/2007
BREEN, NICHOLAS DMD 10/2/1961 1730307836 7731 RUDDEROW AVENUE PENNSAUKEN NJ 08109 DISQUALIFICATION 8/18/1995 9/27/2013
BREEN, NICHOLAS DMD 10/2/1961 1730307836 7731 RUDDEROW AVENUE PENNSAUKEN NJ 08109 DISQUALIFICATION 5/14/1996 9/27/2013
BRETTLER, NORMAN AKA
BRETTLER, NORBERT
2/3/1948 401 COUNTRY CLUB DRIVE CHERRY HILL NJ 08003 DISQUALIFICATION 5/12/2016
BREWINGTON, CYNTHIA CHHA 7/3/1962 379 MILLRIDGE ROAD CLEMENTON NJ 08021 DISQUALIFICATION 1/31/2017
BRICK, ROGER MD 12/20/1949 31-33 WEST 11TH STREET NEW YORK NY 10026 SUSPENSION 12/15/2006
BRIGHAM, STEVEN C. MD 8/29/1956 1306012539 1094 CORBRIDGE COURT VOORHEES NJ 08043 DISQUALIFICATION 6/20/2018
BRINT, SAMUEL DO 1/6/1918 515 BIRD WAY CAMDEN NJ 08103 DISQUALIFICATION 12/15/1987
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
18
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BRISTOL, KENNETH RN 1/2/1951 PO BOX 931 FLAGSTAFF AZ 06002 SUSPENSION 10/19/2006
BRIZER, DAVID ALLEN MD 1/22/1953 1518181270 255 W 85TH ST., APT. 5B NEW YORK NY 10024 DISQUALIFICATION 6/30/2014
BRIZER, DAVID ALLEN MD 1/22/1953 1518181270 6766 108TH STREET, APT. A62 FOREST HILLS NY 11375 DISQUALIFICATION 2/20/2015
BROADNAX, DEITRICH 7/12/1965 347 BELLEVILLE AVE., #B8 BLOOMFIELD NJ 07003 DISQUALIFICATION 11/25/1998
BROADWAY MEDICAL
GROUP
227 BROADWAY PATERSON NJ 07501 DISQUALIFICATION
BRODSKY, KONSTANTIN CHHA 1/1/1947 55 WEST 45TH STREET, FL 7R NEW YORK NY 10036 DEBARMENT 5/2/2017
BROOKHIM, ROBEN DDS 8/24/1958 444 MORRIS AVENUE ELIZABETH NJ 07208 SUSPENSION 8/20/2000
BROOKHIM, ROBEN DDS 8/24/1958 120 LAWRENCE DRIVE SHORT HILLS NJ 07078 DISQUALIFICATION 5/20/2015
BROOKMAN, HARVEY W. MD 3/20/1941 301 OXFORD VALLEY ROAD YARDLEY PA 19067 DISQUALIFICATION 4/13/1995
BROOKS JR., OSCAR COUNSEL
OR
11/8/1963 27 E VILLAGE OF STONEY RD MAPLE SHADE NJ 08052 DISQUALIFICATION 4/17/1995
BROOKS, MAUREEN R. LPN 7/9/1954 110 THIRD AVENUE BELMAR NJ 07719 SUSPENSION 10/9/2003
BROWN, ALEXANDRIA N. RN 12/15/1965 803 DAWN LANE WILLIAMSTOWN NJ 08094 SUSPENSION 5/19/2005
BROWN, DEANNA CHHA 12/17/1988 611 B. BINGHAM STREET NEPTUNE NJ 07753 DISQUALIFICATION 1/23/2018
BROWN, DERVENT CHHA 9/20/1959 151 FIRST STREET ENGLEWOOD NJ 07631 DEBARMENT 1/26/2018
BROWN, IMAN CHHA 10/20/1983 717 N. MICHIGAN AVENUE ATLANTIC CITY NJ 08401 DEBARMENT 7/14/2017
BROWN, KAYDIA CHHA 8/24/1985 1033 SEWALL AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 1/31/2017
BROWN, LAFONDA CHHA 5/20/1976 485 EAST 19TH STREET, APT.
#4-F
PATERSON NJ 07524 DEBARMENT 10/26/2017
BROWN, ROGER H. DMD 5/12/1955 1457460305 601 ROUTE 206, UNIT 30 BELLE MEAD NJ 08844 DEBARMENT 5/27/2005
BROWN. SAO LPN 10/30/1964 9 ALAN STREET WEST ORANGE NJ 07052 DEBARMENT 6/5/2017
BROWN-COLEY, KELLI LPN 7/10/1967 88 WEST 6TH STREET BAYONNE NJ 07002 DISQUALIFICATION 10/11/2017
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
19
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BRUGOS, LEALYNN CHHA 1/31/1994 636 BILLINGS AVENUE PAULSBORO NJ 08066 DISQUALIFICATION 1/31/2017
BRUNELLE, ELIZABETH LPN 10/13/1950 5902 EAST 2ND STREET TUCSON AZ 85711 SUSPENSION 10/19/2006
BRYANT-DERRICK, KISHARA LPN 10/18/1967 107 DEAL AVENUE NEPTUNE NJ 07753 DISQUALIFICATION 9/12/2016
BUCKLEY, MARIANNE LPN 1/3/1926 83 IRVING COURT TRENTON NJ 08610 SUSPENSION 5/20/2001
BUITRAGO, CARMEN LPN 8/2/1975 412 CLIFF STREET, APT. 1 FAIRVIEW NJ 07022 DISQUALIFICATION 7/12/2018
BULGER, PATRICE RN 2/16/1963 117 MILL CREEK RD. BAYVILLE NJ 08721 DISQUALIFICATION 7/15/2002
BULLARD, ANGELA CHHA 2/5/1989 268 E. 21ST STREET, 3RD FL. PATERSON NJ 07513 DISQUALIFICATION 12/26/2017
BUNCH, LATITIA LPN 9/9/1971 212 S. 27TH STREET CAMDEN NJ 08105 SUSPENSION 2/20/2002
BUNN, YAHMINAH CHHA 9/26/1983 22 GATLING COURT NEW BRUNSWICK NJ 08901 DISQUALIFICATION 5/2/2017
BUONO, DONNA RN 10/17/1964 61 S. LOCUST AVENUE MARLTON NJ 08053 SUSPENSION 9/19/2003
BURDETTE, KAYLA F. CHHA 10/26/1990 31 ISLAND AVENUE SEASIDE PARK NJ 08752 DISQUALIFICATION 11/14/2014
BURKARD, JUDITH LPN 5/2/1956 320 7TH AVENUE, APT. 16 ASBURY PARK NJ 07712 DISQUALIFICATION 11/23/2009 11/23/2010
BURKE, WILLIAM MD 8/3/1937 PO BOX 670 NEW VERNON NJ 07976 SUSPENSION 11/20/2006
BURKES, JEFFREY DDS 7/21/1948 1073690137 176 LAKEWOOD AVENUE HO-HO-KUS NJ 07423 DISQUALIFICATION 2/19/2009
BURKETT, EILEEN PHARM
TECH
11/30/1952 1407 VIRGINIA COURT MARLTON NJ 08053 SUSPENSION 4/20/2011
BURNETT, RASHEEDAH CHHA 1/26/1983 860 SOUTH 11TH STREET,
APT. 4-B
NEWARK NJ 07108 DISQUALIFICATION 1/31/2017
BURNS, MARGARET 12/9/1952 2429 WESTFIELD AVENUE SCOTCH PLAINS NJ 07076 SUSPENSION 9/19/2003
BURWELL-ADENIJI, LORIN CHHA 12/19/1987 1004 HIGH STREET BURLINGTON NJ 08016 DISQUALIFICATION 2/20/2017
BUSSEY, PAUL MD 10/22/1969 1356341424 1 MILL STREET WOODSTOWN NJ 08098 DEBARMENT 10/13/2015
BUTT, ATIQ 2/2/1959 2524 FORD RD. BRISTOL PA 19007 DISQUALIFICATION 6/15/2001
BUTTERHOF, TRACY RN 8/13/1960 501 S. BERLIN AVENUE EGG HARBOR CITY NJ 08215 SUSPENSION 4/20/2003
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
20
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
BYADGI, CHETHAN MD 8/8/1963 1063537215 LACKAWANNA COUNTY
PRISON, 1371 NORTH
WASHINGTON AVENUE
SCRANTON PA 18509 DISQUALIFICATION 7/20/2017
BYERS, RAYMOND AKA
BYERS, FAYE
R & B
TRANS
2/6/1943 44 PALM STREET, FL. 2 NEWARK NJ 07106 DEBARMENT 10/14/2005
CABALEIRO, YODALIO MD 12/3/1930 3700 KENNEDY BLVD. UNION CITY NJ 07087 DISQUALIFICATION 4/18/1986
CABALERIO, THERESA 4611 BERGENLINE AVENUE UNION CITY NJ 07087 DISQUALIFICATION 6/1/1993
CABAN, DESTINY CHHA 9/18/1996 105 BOYD STREET CAMDEN NJ 08105 DISQUALIFICATION 2/8/2017
CABATIC, VIRGINIA C. RN 6/11/1940 14 SPARROW RD. RANDOLPH NJ 07869 SUSPENSION 5/19/2005
CABRERA, RAMON BRETON 6/29/1959 486 ZAMBORY STREET PERTH AMBOY NJ 08861 DEBARMENT 9/19/2011
CACERES, MARIO 8/26/1958 328 MARKET STREET CAMDEN NJ 08102 SUSPENSION 10/20/1998
CACERES, MARIO 8/26/1958 328 MARKET STREET CAMDEN NJ 08102 SUSPENSION 10/5/2000
CACI, FRANCIS R. DDS 248 SOUTH SUMMIT AVENUE HACKENSACK NJ 07601 DISQUALIFICATION 12/8/1997 DECEASED
CACOILO, MARIA 10/31/1967 1150 AMBOY AVENUE EDISON NJ 08837 DISQUALIFICATION 4/29/2003
CAI, PING DMD 11/15/1962 1275667362 22 SAGE STREET HOLMDEL NJ 07733 DISQUALIFICATION 9/10/2012 9/15/2017
CALABRESE, ANGELO MD 6/12/1957 1891722237 FCI-SCHUYKILL, PO BOX 759 MINERSVILLE PA 17954 DISQUALIFICATION 1/22/2016
CALDERON, TANISHA CHHA 11/26/1977 108 N. 16TH EAST ORANGE NJ 07019 SUSPENSION 3/20/2002
CALLAHAN, VICTORIA PHARM
TECH
5/23/1979 130 FROST AVENUE PHILLIPSBURG NJ 08865 DISQUALIFICATION 7/21/2017 PERMANENT
CALVELO, ARSENIO C. RN 3/15/1953 13515 SCENIC GLADE DR. HOUSTON TX 77059 SUSPENSION 6/19/2003
CAMACHO, OLGA CHHA 8/13/1969 176 KNAPP AVENUE CLIFTON NJ 07011 DISQUALIFICATION 1/17/2018
CAMP, SUZANNE RN 5/18/1954 PO BOX 423 PORT ELIZABETH NJ 08348 SUSPENSION 10/21/2010
CAMPANELLA-KAPLAN,
DONNA
LPN 2/12/1970 1355 W. POINT AVENUE MAYS LANDING NJ 08330 DISQUALIFICATION 4/10/2018
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
21
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CAMPBELL JR., HIGHLAND MD 11/26/1966 1043270143 1009 MEADOWVIEW LANE MONT CLARE PA 19453 DISQUALIFICATION 11/20/2015
CAMPIONE JR., FRANK PA 3/10/1970 1598856924 431 STONEY POINT ROAD BRICK NJ 08733 DISQUALIFICATION 9/16/2016
CANALES JR., DELOVI 10/3/1966 11 ALBERT STREET TOMS RIVER NJ 08953 DEBARMENT 4/30/2010 4/30/2013
CANARES, ALEXANDER RN 11/23/1977 60 BROOKSIDE AVENUE, APT.
2B
SOMERVILLE NJ 08876 DISQUALIFICATION 5/2/2018
CANE, LAMONT NURSES
AIDE
PO BOX 90431 CAMDEN NJ 08012 SUSPENSION 8/18/1997
CANNON, JEROME 1/20/1965 4221 NORTH 6TH STREET PHILADELPHIA PA 19140 DISQUALIFICATION 12/29/2015
CANTAVE, MARIE CHHA 7/20/1979 1217 OCEAN AVENUE, APT. C-
12
BRADLEY BEACH NJ 7720 DISQUALIFICATION 4/18/2017
CANTERMEN, LYNN RN 11/3/1975 518 N. HILDEBRAND AVENUE GLENDORA NJ 8029 DISQUALIFICATION 5/2/2018
CAPACIO, RICHARD DC 10/3/1958 1245230929 99 ANNAPOLIS DRIVE SICKLERVILLE NJ 08081 SUSPENSION 12/20/2006
CAPILLI, MICHAEL A. DC 5/14/1960 427 HOYT STREET LONG BRANCH NJ 07740 SUSPENSION 8/9/2001
CAPITANO, PETER RPH 2/7/1955 SCHUYLKILL FCI, PO BOX 759 MINERSVILLE PA 17954 DISQUALIFICATION 11/20/2015
CAPO. LASARAH CHHA 9/22/1988 50-52 ROSA PARK
BOULEVARD, APT. 5
PATERSON NJ 07501 DISQUALIFICATION 1/31/2017
CAPOBIANCO, LEO J. DO 3/19/1966 1063483097 7 CASTLE COURT RANDOLPH NJ 07860 DISQUALIFICATION 9/5/2002 6/8/2018
CAPPIELLO, RAFAEL MD 7/20/1930 2704 BRIENZA WAY LAS VEGAS NV 89117 DEBARMENT 8/19/1999
CAPRIOLA, EDWARD MD 7/20/1942 313 S. FRANK ROGERS HARRISON NJ 07029 SUSPENSION 12/20/2006 DECEASED
CARABALLA, CARLA CHHA 1/25/1958 742 EAST SEVENTH STREET PLAINFIELD NJ 07062 DISQUALIFICATION 6/13/2017 PERMANENT
CARAGINE JR., PAUL J. MD 5/1/1945 1 SAWMILL RD. KINNELON NJ 07504 DISQUALIFICATION 7/18/2001
CARCHIA, ETTORE DC 8/21/1960 994 SANDY CIRCLE MANAHAWKIN NJ 08050 SUSPENSION 2/20/2006
CARDENAS, PRESENTACION
E.
RN/LPN 11/21/1953 274 BATH AVENUE, #22 LONG BRANCH NJ 07740 SUSPENSION 5/20/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
22
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CARDILLO, JOHN 7/18/1956 162 GARFIELD STREET BERKELEY HEIGHTS NJ 07922 SUSPENSION 9/4/2005
CARDILLO, JOHN 7/18/1956 162 GARFIELD STREET BERKELEY HEIGHTS NJ 07922 DEBARMENT 5/20/2006
CARDILLO, RICHARD C. MD 7/22/1955 1477520807 2893 BIRCH RD. SUAMICO WI 54173 DEBARMENT 3/27/2002
CARDINAL, PETER MD 11/29/1958 1104985142 520 WALNUT STREET, APT. 3 LEMOYNE PA 17043 DISQUALIFICATION 11/20/2015
CARDOSO SR., LUCIO MD 6/23/1958 1639119019 253 LAFAYETTE STREET NEWARK NJ 07105 SUSPENSION 2/22/2012
CARDOSO SR., LUCIO MD 6/23/1958 1639119019 FCI FORT DIX FORT DIX NJ 08640 DISQUALIFICATION 2/3/2014
CAREPOINT MEDICAL 1396744694 4860 COX RD., SUITE 300 GLEN ALLEN VA 23060 DISQUALIFICATION 11/20/2015
CAREY JR., CHARLES B. 2/1/1979 218 BRIANT PARK DRIVE SPRINGFIELD NJ 07081 DISQUALIFICATION 5/20/2015
CARIDAD, MICHELLE CHHA 1/22/1971 10 BROOKSIDE COURT TOMS RIVER NJ 08753 DISQUALIFICATION 2/8/2017
CARIDEO, IDA MD 2/18/1957 1578842977 7 MALKE DRIVE WAYSIDE NJ 07712 DISQUALIFICATION 6/7/1999 8/1/2012
CARINO, JOVY 12/15/1964 37 JAMES STREET BLOOMFIELD NJ 07003 SUSPENSION 5/29/2009
CARLSON, LILLIAN MAE RN 8/5/1956 275 HIGH STREET APT. Q334 GLASSBORO NJ 08028 DISQUALIFICATION 6/18/2009
CARLUCCI JR., WILLIAM A. RPH 9/7/1943 1902120363 FCI FORT DIX FORT DIX NJ 08640 DEBARMENT 9/25/2014
CARLUCCI, ROBERT A. RPH 9/7/1943 1639493091 PO BOX 759 MINERSVILLE PA 17954 DEBARMENT 9/25/2014
CARMONA, ALICE Y. 12/9/1957 78 DAWN STREET VINELAND NJ 08302 DEBARMENT 10/23/2000
CARR, JOEL R. DO 1/1/1960 1275586489 8 JASMINE RD. LUMBERTON NJ 08048 SUSPENSION 3/2/2011
CARR, PATRICIA 8/1/1947 PO BOX 91 BROWNS MILLS NJ 08015 DISQUALIFICATION 7/19/2001
CARRION, NANCY CHHA 7/18/1979 76 ZABRISKIE STREET JERSEY CITY NJ 07307 DEBARMENT 3/5/2018
CARROLL, KIMBERLY J. LPN 7/3/1964 18 LEE AVENUE HADDONFIELD NJ 08033 DISQUALIFICATION 8/18/2011
CARSON, YOLANDA CHHA 11/21/1968 65 DALES AVENUE, APT. 1137 JERSEY CITY NJ 07306 DISQUALIFICATION 1/31/2017
CARTER, DARRICKA C. DPM 1/1/1965 2505 ST. REGIS DRIVE RICHMOND VA 23236 DISQUALIFICATION 7/20/2010
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
23
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CARUSO, EDMUND M. DMD 7/30/1958 1811132442 2275 KENNEDY BLVD. JERSEY CITY NJ 07304 DISQUALIFICATION 11/10/1994
CASAS, JOSE MD 12/23/1933 215 PASSAIC AVENUE PASSAIC NJ 07055 DEBARMENT 5/24/1999
CASAVINA, PHILIP 5/11/1929 244 KNOX AVENUE CLIFFSIDE PARK NJ 07650 DISQUALIFICATION
CASCIO, DANIEL RN 3/5/1956 17 SEGUR STREET DOVER NJ 07801 SUSPENSION 5/20/2002
CASTANEDA, JOSE E. APN 11/3/1974 1699840264 1925 PACIFIC AVENUE ATLANTIC CITY NJ 08401 SUSPENSION 2/22/2012
CASTANEDA, JOSE E. APN 11/3/1974 1699840264 194 E. 7TH STREET CLIFTON NJ 07011 DISQUALIFICATION 1/26/2015
CASTANON, ROBERTO 5/1/1947 555 GEO DRIVE PHILLIPSBURG PA 16866 DISQUALIFICATION 9/16/2011
CASTELLANO, DOLORES PASSAIC
FAMILY
MEDICAL
4/8/1949 4300 SW 57TH STREET MIAMI FL 33155 SUSPENSION 6/17/2004
CASTILLO, HECTOR L. MD 4/18/1956 1528198124 1000 MADISON AVENUE PATERSON NJ 07501 DEBARMENT 2/19/2012
CASTILLO, STEVEN A. DDS 4/21/1962 PO BOX 16421 JERSEY CITY NJ 07306 DISQUALIFICATION 5/5/1997
CATANZARO, DANIEL DC 10/19/1959 28 ETOWAH RIDGE DRIVE, SW CARTERSVILLE GA 30120 SUSPENSION 12/20/2005
CATANZARO, VINCENT F. MD 5/22/1947 560 MAIN STREET ALLENHURST NJ 07711 DISQUALIFICATION 6/1/1993 DECEASED
CAVALLI, DEAN 762 BROADWAY CAMDEN NJ 08103 DISQUALIFICATION
CAVE, SANDY 3/10/1972 109 BOBWHITE RD. ROYAL PALM BEACH FL 33411 DISQUALIFICATION 5/20/2012
CECE, ANGELO DMD 5/25/1957 1033396593 566 NYE AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 1/19/1996
CEDENO, HUMBERTO RPH 2/11/1925 601 ELIZABETH AVENUE ELIZABETH NJ 07206 DISQUALIFICATION 5/3/1984
CENTRAL DIAGNOSTICS
LAB
256 SMITH STREET PERTH AMBOY NJ 08861 DISQUALIFICATION 5/8/1989
CENTRAL JERSEY MENTAL
CENTER
525 PARK AVENUE PLAINFIELD NJ 07067 DISQUALIFICATION
CENTRELLI, MARC DC 8/1/1960 176 ALPINE TRAIL SPARTA NJ 07871 SUSPENSION 7/21/2008
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
24
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CHA, DONG S. MD 5/1/1938 608 S. BROAD STREET WOODBURY NJ 08096 DISQUALIFICATION 12/1/1998
CHACK, JOEL DO 3/11/1956 1093739096 5 GWEN COURT CHERRY HILL NJ 08003 DISQUALIFICATION 8/13/2011 1/6/2012
CHAI, CHRISTINA RPH 8/20/1984 1689997835 2461 LEIGHTON STREET FORT LEE NJ 07024 DISQUALIFICATION 3/24/2016
CHAIKEN, BARBARA LCSW 4/8/1952 1871768465 419 OTISCO DRIVE WESTFIELD NJ 07090 DISQUALIFICATION 6/1/1993
CHAM, WILLIAM C. MD 8/15/1938 11 HICKORY DRIVE CHESTER TWP. NJ 07930 SUSPENSION 8/29/1997
CHAMBERS, CAROL CHHA 9/25/1956 1022 STUYVESANT AVENUE IRVINGTON NJ 07111 SUSPENSION 1/20/2004
CHAMPION, MARY
MARGARET
RN/CHHA 9/26/1963 91 MOUNT AIRY AVENUE,
SOUTH
EGG HARBOR NJ 08234 SUSPENSION 6/20/2005 6/11/2013
CHANDLER, BRYAN K. 6/15/1967 10 ELLINGTON STREET, #1 EAST ORANGE NJ 07017 DISQUALIFICATION 8/28/2008
CHANDLER, CHARLES PA 10/11/1958 1417996901 219 N. WALNUT STREET, FL. 1 EAST ORANGE NJ 07017 DISQUALIFICATION 11/4/2009
CHANSKY, CHRISTINE MD 8/19/1968 1508125600 820 NORTH AVENUE WESTFIELD NJ 07090 DISQUALIFICATION 3/20/2018
CHAPLAN, ABRAHAM MD 11/17/1929 384 NORTH WOODLAND ST. ENGLEWOOD NJ 07631 DISQUALIFICATION 6/1/1993
CHARLES, ESTHER CHHA 7/22/1987 380 UNION AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 3/6/2018
CHATMON, ALTON RPH 4/10/1970 1790091742 RR8, BOX 370 BRIDGETON NJ 08302 DEBARMENT 3/3/2017
CHAUDHRY, YASMIN T. 1/18/1962 333 NORTH BROAD STREET ELIZABETH NJ 07028 SUSPENSION 7/21/1997
CHEESE, EPHONIA CHHA 11/15/1989 18 PATRIOT LANE WILLINGBORO NJ 08046 DISQUALIFICATION 5/16/2018
CHEN, BONNIE MD 1/14/1964 1750373486 243 HORSENECK ROAD FAIRFIELD NJ 07004 DISQUALIFICATION 8/12/2018 PERMANENT
CHEN, KENNETH H. MD 5/23/1937 244 BROADWAY NEWARK NJ 07104 SUSPENSION 5/7/1999
CHEN, TAN MD 6/10/1945 12 LORRAINE DRIVE PINE BROOK NJ 07058 DISQUALIFICATION 11/5/1999
CHERVIN, ARON 7/18/1947 36 LAKE DRIVE NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 2/11/2016
CHESTON, EBONY CHHA 11/17/1981 33 NEWELL AVENUE TRENTON NJ 08618 DISQUALIFICATION 3/6/2018
CHHADEH, AHED 3/25/1974 401 NEW BRUNSWICK AVE.,
APT 221
EAST BRUNSWICK NJ 08816 DISQUALIFICATION 11/21/2016
CHIAPPETTA, THERESA 7/6/1974 8 STEINHARDT AVENUE OLD BRIDGE NJ 08857 DEBARMENT 9/15/2008
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
25
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CHIAPPETTA, THERESA 7/6/1974 8 STEINHARDT AVENUE OLD BRIDGE NJ 08857 DISQUALIFICATION 11/12/2009
CHILDREN'S DENTAL
CENTER
1992974406 3700 KENNEDY BLVD. UNION CITY NJ 07087 DEBARMENT 9/15/2017
CHILLEMI, SALVATORE 7/10/1962 29 BERKSHIRE DRIVE SEWELL NJ 08080 DISQUALIFICATION 6/10/2011
CHIRUMAMILLA, RAMABU RPH 212 E. PITTSBURGH AVENUE WILDWOOD CREST NJ 08260 DISQUALIFICATION 3/11/1985
CHIZHOV, ELLA 12/24/1946 200 WINSTON DRIVE #C1104 CLIFFSIDE PARK NJ 07010 SUSPENSION 7/21/2008
CHIZHOV, SERGEY 6/12/1946 200 WINSTON DRIVE CLIFFSIDE PARK NJ 07010 DISQUALIFICATION 9/20/2007
CHLOROS, STACY LPN 6/11/1974 323 GILL LANE ISELIN NJ 08830 SUSPENSION 5/18/2006
CHOI, JEHEE RN 11/27/1965 31 PINE RIDGE LANE MANSFIELD CENTER CT 06250 DISQUALIFICATION 3/27/2018
CHRISTENSEN, CYNTHIA RN 12/22/1962 20 SKYLINE DRIVE HAZLET NJ 07730 SUSPENSION 10/18/2001
CHRISTJOHN, COLLEEN M. LPN 10/27/1964 CORSON RD. SOUTH SEAVILLE NJ 08246 DISQUALIFICATION 8/11/2007
CHRISTMAS, ARTHUR 6/7/1978 66 NORTH 11TH STREET NEWARK NJ 07107 DEBARMENT 6/16/2006
CHUDRY, RAZA 4/6/1959 RD #5 FEDERAL PRISON LEWISBURG PA 17837 SUSPENSION 9/19/2002
CHUKWUANI, ROSETTA CHHA 2/5/1962 3 LISZKA LANE SAYREVILLE NJ 08872 SUSPENSION 2/28/2009
CHULAK, GENADY 9/4/1955 242 COMMUNITY CIRCLE OLD BRIDGE NJ 08857 DISQUALIFICATION 4/15/1996
CHUNMUANG, PRASERT MD 5/15/1942 401 DEVONSHIRE PL. FRANKLIN LAKES NJ 07417 DISQUALIFICATION 6/14/1993
CHUPREVICH, EILEEN D. RN 11/15/1948 8 STANTON PLACE BUTLER NJ 07405 SUSPENSION 1/20/2003
CICCONE, GREGORY 12/22/1976 5 WATERS EDGE DR. LITTLE EGG HARB NJ 08087 SUSPENSION 5/15/2005
CICERO, BARBARA RN 6/12/1937 91 LINCOLN AVENUE SOMERVILLE NJ 08876 SUSPENSION 8/20/2001
CICERO, RALPH DDS 5/8/1944 1740449305 245 BALDWIN STREET SUCCASUNNA NJ 07876 DEBARMENT 3/6/2014
CITILAB CORPORATION 333 NORTH BROAD STREET ELIZABETH NJ 07028 SUSPENSION 12/1/1998
CLACKLEY, MACK O. LPN 3/9/1962 PO BOX 150 DELMONT NJ 08314 SUSPENSION 9/20/2001
CLAPPER, STEPHANIE LPN 11/19/1979 169 NAUTILUS MANAHAWKIN NJ 08050 DISQUALIFICATION 2/26/2010
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
26
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CLARK, INDIA CHHA 8/24/1989 5 SECOND AVENUE TOMS RIVER NJ 08757 DISQUALIFICATION 7/14/2017
CLARK, JAMES 9/26/1955 380 MOUNTAIN RD. #12 UNION CITY NJ 07087 SUSPENSION 9/27/2007
CLARK, JOVONNE CHHA 12/1/1983 1605 SEWALL AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 8/22/2017
CLARK, KEVIN 9/16/1956 537 TRINITY PLACE WESTFIELD NJ 07090 SUSPENSION 10/5/2009
CLARK, MICHELLE CHHA 5/27/1971 75 NORTH WALNUT STREET,
APT. 6C
EAST ORANGE NJ 07017 DISQUALIFICATION 1/30/2017 PERMANENT
CLARK, NORMAN L. MD 7/14/1952 5 TARA DRIVE PARSIPPANY NJ 07054 SUSPENSION 3/2/1999
CLARK, NYKEBA CHHA 4/7/1980 807 N. INDIANA AVENUE ATLANTIC CITY NJ 08401 DEBARMENT 1/24/2018
CLARK, RAYONNE 9/25/1979 844 CENTRE STREET TRENTON NJ 08611 SUSPENSION 7/20/2003
CLARK, RAYONNE 9/25/1979 844 CENTRE STREET TRENTON NJ 08611 DISQUALIFICATION 8/13/2003
CLAVIJO, LAURA RN 7/5/1981 908 CLARK CIRCLE FLEMINGTON NJ 08822 DISQUALIFICATION 8/28/2017
CLEMENTE, JOHN MD 4/11/1955 1982933271 20 PILGRIM WAY COLTS NECK NJ 07722 DEBARMENT 11/29/2015
CLEMENTE, JOHN MD 4/11/1955 1982933271 20 PILGRIM WAY COLTS NECK NJ 07722 DISQUALIFICATION 4/20/2015
CLEMMENTS, RALPH W. MD 11/16/1923 7304 CENROSE CIRCLE WESTWOOD NJ 07675 DEBARMENT 9/12/2008
CLIN-PATH LABORATORY,
INC.
626 N. 38TH STREET BELLEVILLE IL 62223 DISQUALIFICATION 6/4/1997
COBB, ROY MD 3/3/1957 1548350556 504 SUMMIT AVENUE MAPLEWOOD NJ 07040 DISQUALIFICATION 6/5/2017 PERMANENT
COBB, WILLIAM A. MD 10/20/1942 1679666903 2 WEST RIVER STYX ROAD HOPATCONG NJ 07843 DEBARMENT 3/16/2011 PERMANENT
COCCO, KRISTEN RN 4/22/1975 44 SYRACUSE DRIVE CHERRY HILL NJ 08056 DISQUALIFICATION 6/5/2017
CODDINGTON, DE'LYNNE CHHA 12/15/1992 904 MAIN STREET BRADLEY BEACH NJ 07720 DISQUALIFICATION 11/8/2017
COHEN, BARRY E. 5/19/1953 6326 NW 80TH TERRACE POMPANO BEACH FL 33067 SUSPENSION 3/20/2006
COHEN, JUDAH L. MD 8/31/1953 1000 GALLOPING HILL RD. UNION NJ 07083 DISQUALIFICATION 4/24/1998
COHEN, ROBERT G. RN/APN 11/16/1950 51 KRISTEN COURT MATAWAN NJ 07747 DISQUALIFICATION 3/24/2003
COHEN, WENDY E. MD 3/23/1944 1619024056 151 N. DEAN STREET ENGLEWOOD NJ 07631 SUSPENSION 5/10/2012 DECEASED
COLADONATO, JOSEPH MD 5/28/1943 9760 EVERGREEN AVENUE SEAFORD DE 19973 DEBARMENT 2/3/2006
COLBERT, DONNA CHHA 2/24/1956 183 ROUTE 35 WALL TOWNSHIP NJ 07719 DISQUALIFICATION 7/14/2017 PERMANENT
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
27
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
COLEMAN, BARBARA CHHA 3/8/1950 81 LINCOLN PARK, APT. 5B NEWARK NJ 07102 DISQUALIFICATION 1/31/2017
COLEMAN, BETH RN 11/14/1975 1598919466 12 NORTH ELMIRA STREET ATHENS PA 18810 DISQUALIFICATION 5/12/2016
COLETTI, ROGER MD 12/22/1945 1770508053 324 CAPTAINS CL. LEWES DE 19958 DISQUALIFICATION 1/5/2018 PERMANENT
COLEY, CHERYL CHHA 3/16/1994 17 NORTH 3RD STREET PATERSON NJ 07522 DISQUALIFICATION 1/22/2018
COLLIER, BERT D. MD 12/6/1947 4933 N. WILDWOOD AVENUE MILWAUKEE WI 53217 DEBARMENT 5/29/2001 9/20/2013
COLLIER, KENYA CHHA 9/19/1980 708 THIRD AVENUEM APT. 13-
B
ASBURY PARK NJ 07712 DISQUALIFICATION 1/31/2017
COLLIER, KISHA CHHA 7/20/1990 54 FEDERAL COURT GALLOWAY NJ 08205 DISQUALIFICATION 5/2/2017
COLLINS, JEAN RN 6/10/1957 218 COPELAND AVENUE LYNDHURST NJ 07071 DISQUALIFICATION 4/24/2018
COLON, KAREN L. LPN 11/29/1973 1020 MCGUIRE DRIVE TOMS RIVER NJ 08753 SUSPENSION 6/20/2005
COLON-TORRES, FRANCIS
M.
3/28/1973 437 STUYVESANT AVENUE IRVINGTON NJ 07111 SUSPENSION 11/7/2008
COMESANAS, MARIO MD 11/25/1955 1508922659 COLUMBIA TPK. FLORHAM PARK NJ 07932 DISQUALIFICATION 8/10/2007
COMPAS, JEAN CLAUDE MD 11/6/1948 1720178148 255 EASTERN PARKWAY, APT.
D3
BROOKLYN NY 11238 DISQUALIFICATION 7/20/2015
COMRIE, SHIRLEY M. CHHA 7/22/1957 7 DUFFELD DRIVE TRENTON NJ 08628 SUSPENSION 7/18/2002
CONARD, MICHELLE LPN 3/26/1955 16 ELDRIDGE AVENUE TRENTON NJ 08648 DISQUALIFICATION 7/20/2009
CONNERS, LAURA LPN 6/9/1976 11 FENWAY RD. HAMILTON NJ 08620 SUSPENSION 3/20/2002
CONOVER, WILLIAM S. LPN 7/23/1965 225 RUTLAND AVENUE MT. HOLLY NJ 08060 SUSPENSION 5/20/2004
CONTEH, AMARA S. MD 8/10/1943 3 OLD TAPPAN RD. OLD TAPPAN NJ 07675 SUSPENSION 9/20/2007
CONTI, VINCENT MFT 1/20/1935 1023189644 180 PROSPECT AVENUE MORRIS PLAINS NJ 07950 DISQUALIFICATION 9/23/2016
COOPER STREET
PSYCHIATRIC GROUP
301 COOPER STREET CAMDEN NJ 08012 DISQUALIFICATION 5/2/1990
COPLIN, GEORGE J. MD 1/23/1908 528 EAST JERSEY ST ELIZABETH NJ 07206 DISQUALIFICATION 6/1/1993 DECEASED
CORNELY, MICHAEL P. DC 12/11/1962 1326199803 6650 BROWINING RD. MERCHANTVILLE NJ 08109 DISQUALIFICATION 12/1/1998
CORSON, KENNETH E. MD 5/12/1904 5 SOUTH MYRTLE ST VINELAND NJ 08360 DISQUALIFICATION
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
28
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CORTEZ, JESSICA CHHA 4/21/1983 114 EDWARDS AVENUE LANDISVILLE NJ 08326 DISQUALIFICATION 9/6/2017
COSTA, LAWRENCE J. 4/25/1948 441 PENN AVENUE FORKED RIVER NJ 08731 DISQUALIFICATION
COSTIGAN, KEVIN LCSW 8/26/1955 132 FRANKLIN AVENUE, APT.
2
LONG BRANCH NJ 07740 SUSPENSION 3/21/2000
COSTINO JR., JOHN DO 7/22/1944 1811978414 404 SURF AVENUE WILDWOOD NJ 08260 DISQUALIFICATION 8/18/2011
COTTRELL, LISA L. CHHA 8/12/1963 290 ROUTE 9 NORTH, APT C5 WARETOWN NJ 08758 DISQUALIFICATION 9/30/2010
COUCH FISHER, SUSAN CHHA 10/5/1955 10 PLACID LANE WILLINGBORO NJ 08046 DISQUALIFICATION 2/8/2017
COUGHLIN, CATHERINE K. RN 8/29/1956 PO BOX 22 LIMESTONE PA 16234 DISQUALIFICATION 9/18/2009
COVERDALE, JULIE ANN RN 8/3/1962 909 CINNAMINSON AVENUE PALMYRA NJ 08065 SUSPENSION 4/20/2003
COVILLE, FREDERICK A. MD 9/29/1957 1679728307 230 N. MAPLE AVENUE MARLTON NJ 08050 DEBARMENT 4/17/1997 8/16/2012
COVILLE, FREDERICK A. MD 9/29/1957 1679728307 51-37 HAVENUEN AVENUE OCEAN CITY NJ 08226 DISQUALIFICATION 10/26/1998 8/16/2012
COVONE, DOMINICK 7/14/1949 FORT DIX FCI, BOX 38 FORT DIX NJ 08640 DISQUALIFICATION 10/18/2001
COWAN JR., JAMES MD 3/19/1944 1063527026 572 WEST SADDLE RIVER
ROAD
RIDGEWOOD NJ 07450 DISQUALIFICATION 9/20/2016 PERMANENT
COWAN JR., JAMES MD 3/19/1944 1063527026 28 W. 3RD STREET, APT. 1347 SOUTH ORANGE NJ 07079 DISQUALIFICATION 12/6/2017 PERMANENT
COWAN, MARYANNE LCSW 4/20/1954 572 WEST SADDLE RIVER
ROAD
RIDGEWOOD NJ 07450 DISQUALIFICATION 12/21/2016 DECEASED
CRAPANZANO SR., PETER DDS 1/16/1950 1861566960 46 VILLAGE COURT HAZLET NJ 07730 SUSPENSION 4/26/2011
CRAWFORD, KENNETH CNA 10/13/1962 B-8 ABBINGTON DRIVE PHILLIPSBURG NJ 08865 DISQUALIFICATION 4/6/2006
CRAWFORD, KENNETH CNA 10/13/1962 199A FIDDLER ELBOW RD. PHILLIPSBURG NJ 08865 SUSPENSION 8/20/2006
CRAY, JASON E. COTTAGE
AIDE
7/8/1969 WARREN COUNTY JAIL BELVIDERE NJ 07823 DISQUALIFICATION 8/21/2000
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
29
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CRISCITO, MARIO MD 5/22/1939 1063411957 32 CHELSEA DRIVE LIVINGSTON NJ 07039 DISQUALIFICATION 7/1/2017 PERMANENT
CRISSIEN, CINDY 3/4/1982 78 FORNELIOUS AVENUE CLIFTON NJ 07013 SUSPENSION 1/18/2007
CRITCHFIELD, CYNTHIA AKA
SULLIVAN, CYNTHIA
RPH 6/12/1966 PIN OAK COURT SHAMONG NJ 08088 SUSPENSION 4/20/2008 6/15/2017
CROCKER JR., KENNETH W. 12/11/1975 15 VIOLA AVENUE LEONARDO NJ 07737 DEBARMENT 7/17/2009 7/17/2014
CRON, EVA RN 5/18/1944 31 CHERRY STREET WARWICK NY 10990 SUSPENSION 9/27/2007
CROUSE, FARRELL R. MD 9/20/1932 1386795292 101 NORTH MAIN STREET WOODSTOWN NJ 08098 DEBARMENT 3/18/2015
CROWDER, CLAXTON L. MD 7/1/1942 115 ASHBY COURT MOUNT LAUREL NJ 08054 DISQUALIFICATION 1/13/2006
CROWLEY, TERRI RN 7/27/1959 5 THOREAU ROAD HAMILTON SQUARE NJ 08690 DEBARMENT 11/13/2017
CRUCIANI, RICARDO MD 7/22/1954 1881615268 77 HUDSON STREET, APT.
4401
JERSEY CITY NJ 07302 DISQUALIFICATION 4/16/2018 PERMANENT
CRUZ, ANGELICA CHHA 5/15/1990 2566 SOUTH 8TH STREET CAMDEN NJ 08104 DISQUALIFICATION 7/14/2017
CRUZ, DELIA CHHA 1/19/1988 3 RAY PLACE FAIRFIELD NJ 07004 DEBARMENT 3/5/2018
CRUZ, EDNA CHHA 1/27/1980 PO BOX 535 VINELAND NJ 08362 DISQUALIFICATION 1/31/2017
CRUZ, JAHAIRA CHHA 8/28/1985 559 BAILEY STREET CAMDEN NJ 08102 DISQUALIFICATION 5/2/2017
CRUZ, MARIA C. 4/21/1963 128-65 MCCARTHY CIRCLE PHILADELPHIA PA 19154 DEBARMENT 12/5/2003
CRUZ-SLEDGE, ANICIA 12/28/1961 13 TREMONT STREET, APT. 2 IRVINGTON NJ 07111 DEBARMENT 3/3/2015
CUETO, PAOLA CHHA 7/5/1994 619 THIRTY-EIGHTH STREET UNION CITY NJ 07087 DISQUALIFICATION 10/20/2017
CUFFE, MAXINE RN 9/26/1959 33 GREENBROOK DRIVE BLOOMFIELD NJ 07003 DISQUALIFICATION 3/3/2017
CUI, XIN CHHA 10/17/1968 119 S. ADELAIDE LANE HIGHLAND PARK NJ 08904 DISQUALIFICATION 4/24/2008
CULLEN, CHARLES RN 2/22/1960 PO BOX 861 TRENTON NJ 08625 SUSPENSION 1/18/2007
CULLEN, KENNETH 8/16/1952 100 MARSHALL AVENUE TUCKERTON NJ 08087 SUSPENSION 1/19/2010
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
30
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
CUNNINGHAM, MICHAEL
D.
MD 11/10/1951 PO BOX 505 GLEN SPEY NY 12737 SUSPENSION 9/19/2002
CUPO, DAWN LPN 10/21/1961 129 ADELPHIA RD. FARMINGDALE NJ 07727 SUSPENSION 6/20/2001
CUPOLO, STACY J. DENTAL
HYGIENIS
T
1/5/1962 897 INVERNESS CT., APT. A LAKEWOOD NJ 08701 SUSPENSION 6/20/2005
CURETON, WILLIE T. 8/12/1969 61 CHELSEA AVENUE NEWARK NJ 07106 DISQUALIFICATION 5/27/2011
CURETON, WLLIE T. 8/12/1969 5 UNAMI LANE SCOTCH PLAINS NJ 07076 DISQUALIFICATION 2/23/2009
CURRY JR., CHARLES M. MD 6/3/1943 816 BURNT MILLS RD. OLDWICK NJ 08858 DISQUALIFICATION 12/1/1998
CUSTIS, KEVIN MD 10/3/1964 1811976970 908 MAIN STREET ASBURY PARK NJ 07712 DISQUALIFICATION 7/22/2017
CUVIELLO, CHRISTINA LPN 11/20/1978 1647 WHITTIER AVENUE TOMS RIVER NJ 08753 DISQUALIFICATION 4/24/2018
CZYZYK, LISA M. RN 2/9/1962 12 VILLAGE COURT, APT. A TRENTON NJ 08690 SUSPENSION 9/13/2013
DACONTI, JOHN DO 4/9/1947 1063460939 13 MEDFORD ROAD MORRIS PLAINS NJ 07950 DEBARMENT 6/13/2016
DAFTARY, REKHA B. MD 12/18/1953 81B EAST MAIN STREET MENDHAM NJ 07943 DISQUALIFICATION 2/29/2008
DAHAB, YASIR 5/28/1959 5 PARK STREET ROSELAND NJ 07068 DISQUALIFICATION 12/12/2001
DAHHAN, MOHAMED Z. MD 10/28/1967 1417279779 WINDING WAY WEST PATERSON NJ 07424 SUSPENSION 11/20/2008 4/3/2014
DAILY, GALE CHHA 7/27/1959 14 SUDBERRY LANE WILLINGBORO NJ 08046 SUSPENSION 7/19/2001
DALEY, ROBERTA LPN 2/10/1957 36 HOLLY DRIVE PARLIN NJ 08859 SUSPENSION 8/20/2001
D'ALLEGRO, FRANK RPH 3/26/1928 32 SUMMIT AVENUE CEDAR GROVE NJ 07009 DISQUALIFICATION 8/5/1990
DALTON, ERIN RN 7/4/1980 14 VICTORIAN WAY WEST DEPTFORD NJ 08090 DEBARMENT 2/20/2013
DALY, JAMES J. EMT 9/23/1969 504 EAST FRANKLIN AVENUE EDGEWATER PARK NJ 08010 DISQUALIFICATION 8/7/2013
DALY, LAUREN MD 3/7/1972 1952492233 SCI CAMBRIDGE SPRINGS, 451
FULLERTON AVENUE
CAMBRIDGE
SPRINGS
PA 16403 DISQUALIFICATION 11/20/2015
DALY, LAUREN MD 3/7/1972 1952492233 SCI CAMBRIDGE SPRINGS, 451
FULLERTON AVENUE
CAMBRIDGE
SPRINGS
PA 16403 DISQUALIFICATION 8/5/1990
D'AMICO, DENNIS RPH 4/12/1951 91 OTTOWA RD SOUTH MARLBORO NJ 08817 DISQUALIFICATION 3/11/1985
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
31
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DAMMERS, SEAN 2/22/1978 255 SANTIAGO AVENUE RUTHERFORD NJ 07070 DEBARMENT 9/2/2012
DANIEL, ALAN L. LCSW 5/13/1945 415 KEIM BOULEVARD BURLINGTON NJ 08016 SUSPENSION 8/20/1999
DANIEL, ALAN L. LCSW 5/13/1945 3 HARRISON PARK LANE BURLINGTON NJ 08016 SUSPENSION 3/17/2000
DANIEL, ALAN L. LCSW 5/13/1945 202 SPRING GARDEN RD ANCORA NJ 08037 DISQUALIFICATION 10/20/2002
DANIEL, THERESA D. 6/6/1955 3 HARRISON PARK LANE BURLINGTON NJ 08016 SUSPENSION 3/17/2000
DANIEL-CONOVER, NAHLA CHHA 10/3/1995 191 RUTLEDGE AVENUE EAST ORANGE NJ 07017 DEBARMENT 8/1/2017
DANIELS, BERLYN E. CHHA 8/2/1965 WHITE HORSE AVENUE TRENTON NJ 08610 DISQUALIFICATION 10/13/2008
DANIELS, CLIFTON 12/7/1970 37 HUGHES STREET MAPLEWOOD NJ 07040 DEBARMENT 7/17/2009 7/17/2014
D'ANTIGNAC, CHARLOTTE 12/5/1943 3 CHURCHILL DOWNS W. LONG BRANCH NJ 07764 SUSPENSION 3/10/2000
DARA, PARVEZ MD 4/9/1951 1215952775 214 COMMONS WAY, BLDG B TOMS RIVER NJ 08755 DEBARMENT 10/12/2011
DARBY, MARK COUNSEL
OR
8/9/1968 SBI305830E, EJSP RAHWAY NJ 07065 DEBARMENT 1/1/2010
DARBY, MARK COUNSEL
OR
8/9/1968 SBI305830E, EJSP RAHWAY NJ 07065 DEBARMENT 11/18/2010
D'ASCOLI, BARTHOLOMEW MD 6/3/1949 PO BOX 1869 MONTAGUE NJ 07827 DEBARMENT 8/18/2000
DASS, SUMAN K. MD 10/13/1930 4 BALDWIN AVENUE JERSEY CITY NJ 07304 SUSPENSION 10/4/2000
DASS, SUMAN K. MD 10/13/1930 4 BALDWIN AVENUE JERSEY CITY NJ 07304 DEBARMENT 10/4/2000
DATCHER, ANTHONY 1/31/1984 SCI DALLAS, FOLLIES RD.,
DRAWER K
DALLAS PA 18612 DISQUALIFICATION 11/20/2015
DATESHIDZE, JANE RPH 4/2/1970 617 STOKES ROAD, SUITE 4 MEDFORD NJ 08055 DEBARMENT 6/28/2017
DATILUS, SHELSIE CHHA 3/25/1989 533 NORWOOD STREEET, FL.
1
EAST ORANGE NJ 07018 DISQUALIFICATION 8/22/2017 PERMANENT
DAVID, RICHARD 3/3/1961 819 EDGEWOOD AVENUE TRENTON NJ 08618 DEBARMENT 9/17/2009 2/17/2016
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
32
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DAVIS, ANTOINETTE 6/21/1968 43 VERNON COURT SICKLERVILLE NJ 08081 DISQUALIFICATION 4/23/2007
DAVIS, CHARLES M. COUNSEL
OR
9/18/1950 1902045511 381 BALA AVENUE BALA CYNWYD PA 19004 SUSPENSION 3/31/2008
DAVIS, CONITA CHHA 7/4/1972 2 SUTTON DRIVE, APT. O-1 MATAWAN NJ 07747 DISQUALIFICATION 8/7/2017
DAVIS, COREY 3/20/1969 25 JAMES STREET LAKEWOOD NJ 08701 DISQUALIFICATION 3/12/2006
DAVIS, DEYSHA 12/15/1972 12250 ATLANTIC BOULEVARD
#1701
JACKSONVILLE FL 32225 DISQUALIFICATION 11/20/2015
DAVIS, ESTELLE CHHA 8/11/1974 71 HAMILTON STREET EAST ORANGE NJ 07017 DEBARMENT 5/31/2018
DAVIS, JAMES DANIEL 1/17/1961 145 JUNIPER ST BROWNS MILLS NJ 08015 DISQUALIFICATION 10/4/1988
DAVIS, JAMES S. 11/12/1963 41 B TROY DRIVE SPRINGFIELD NJ 07081 DISQUALIFICATION 9/4/1986 9/4/1994
DAVIS, JEFFREY MD 3/26/1948 1548258189 5 E. 63RD STREET NEW YORK NY 10065 DISQUALIFICATION 11/22/2016
DAVIS, KARIN B. RN 4/15/1971 141 EAST BENNETT AVENUE WILDWOOD NJ 08260 SUSPENSION 10/20/2002 4/14/2014
DAVIS, LORETTA CHHA 7/26/1973 120 CENTRAL PLACE, 202B ORANGE NJ 07050 DEBARMENT 1/19/2018
DAVIS, MARK S. DPM 5/23/1965 5 MONTANA DRIVE COLTS NECK NJ 07722 SUSPENSION 4/9/2004
DAVIS,
MATILDA/MATHILDA
MD 9/23/1926 230 W. JERSEY ST. ELIZABETH NJ 07202 DISQUALIFICATION 6/13/1985
DAVIS, NICOLE RN 3/23/1978 544 ACKLEY ROAD NEWPORT NJ 08345 DISQUALIFICATION 6/4/2018
DAVIS, SHARAE CHHA 7/24/1985 116 LANFORD STREET ASBURY PARK NJ 07712 DISQUALIFICATION 1/31/2017
DAVIS-HARVEY, DIANA RN 3/12/1984 10 CAMINO COURT SICKLERVILLE NJ 08081 DEBARMENT 9/15/2017
DAVIT, SAMUEL MD 7/3/1952 100 WINSTON DRIVE #B CLIFSIDE PARK NJ 07010 SUSPENSION 4/20/2003
DAWLEY, ASHALEY CHHA 3/12/1996 247 MORSE STREET CAMDEN NJ 08105 DISQUALIFICATION 4/19/2018
DAWOUD, MONIR A. MD 12/1/1939 7 COLTSFOOT GLEN SADDLE RIVER NJ 07458 SUSPENSION 11/13/2008
DAWOUD, MONIR A. MD 12/1/1939 7 COLTSFOOT GLEN SADDLE RIVER NJ 07458 DISQUALIFICATION 9/4/2007
DAWSON, LATIA CHHA 5/27/1989 838 4TH AVENUE NEPTUNE NJ 07753 DISQUALIFICATION 7/14/2017
DE LA ROSA ACOSTA,
BIENVENIDA
CHHA 6/15/1969 355 OAK STREET, APT. 8 PASSAIC NJ 07055 DISQUALIFICATION 1/31/2017
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
33
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DEAN, RANDY MD 5/7/1956 1083924807 3991 NORTH WEST 99TH
AVENUE
CORAL SPRING FL 33065 DISQUALIFICATION 11/20/2015
DEANGELO, KRYSTAL RN 7/23/1989 1314 HANCOCK AVENUE VANDERGRIFT PA 15690 DISQUALIFICATION 11/20/2015
DEAQUINO, ANTHONY 3/31/1943 11 STONE RIDGE LANE HO-HO-KUS NJ 07423 DEBARMENT 12/19/2002
DEBIASI, RICK DC 3/23/1964 1861415655 1 ASHLEY PLACE TOWACO NJ 07082 DEBARMENT 6/30/2016
DECASTRO, ANGELA LPN 2/6/1960 894 GOSHEN ROAD CAPE MAY CT
HOUSE
NJ 08210 DISQUALIFICATION 8/29/2016
DEEMI, SAMUEL 8/19/1965 665 MARTIN LUTHER KING
BLVD.
NEWARK NJ 07102 DISQUALIFICATION 10/27/2010
DEFEO, DELORES A. CNM 4/27/1947 RR #6 BOX 280-D PLEASANTVILLE NJ 08232 DISQUALIFICATION 4/26/1996
DEGILIO, MICHAEL PSYD 9/21/1968 1356329528 144 DOGWOOD DRIVE JIM THORPE PA 18229 DISQUALIFICATION 11/20/2015
DEGUZMAN, DAISY MD 1/28/1943 1699865097 111 MULBERRY STREET NEWARK NJ 07102 DISQUALIFICATION 2/20/2014
DEIXLER, GLENN CHHA 9/14/1957 262 PRIVATEER ROAD MANAHAWKIN NJ 08050 DISQUALIFICATION 4/19/2018
DEKU, FAUSTINA CHHA 2/7/1976 10 MARSHALL STREET IRVINGTON NJ 07111 DISQUALIFICATION 2/8/2017
DEL PIANO, ANTHONY MD 3/9/1960 1922032770 24 DRINKING BROOK RD. MONMOUTH
JUNCTION
NJ 08052 DISQUALIFICATION 10/15/2015
DELANCEY, WAYNE K. PHARM
TECH
3/27/1986 1020 HIDEAWAY COURT VINELAND NJ 08361 DISQUALIFICATION 9/16/2011
DELGADO, NICOLE RN 6/21/1990 81 WALNUT STREET OAKLAND NJ 07436 DISQUALIFICATION 1/29/2018
DELGADO, YOKATI CHHA 6/28/1976 175 BRIGHTON AVENUE PERTH AMBOY NJ 08861 DISQUALIFICATION 1/31/2017
DELIA, MICHELLE 3/5/1989 545 W. HILL RD. GLEN GARDNER NJ 08826 DISQUALIFICATION 4/7/2010
DELLAPENNA, LINDA CNA 11/7/1969 52 VAN NESS DRIVE BRICK NJ 08723 DISQUALIFICATION 11/13/2003
DELOACH, LORRAINE CHHA 7/24/1964 9 DAVID STREET, APT. 3 SOUTH RIVER NJ 08882 DISQUALIFICATION 1/31/2017
DELUCA, ANTHONY MD 9/4/1962 1043257744 630 PRINCETON AVENUE BRICK NJ 08724 DISQUALIFICATION 12/16/2015
DELUCA, ANTHONY MD 9/4/1962 1043257744 630 PRINCETON AVENUE BRICK NJ 08724 DEBARMENT 2/11/2016
DELUCA, WENDY RN 10/4/1957 108 GRANDVIEW ROAD HIGHLAND LAKES NJ 07422 DISQUALIFICATION 3/15/2018
DEMARCO, CHARLENE C DO 4/8/1951 PO BOX 898801 OKLAHOMA CITY OK 73189 SUSPENSION 7/20/2008
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
34
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DEMARIA JR., WILLIAM R. 11/1/1959 104 WINDSOR COURT PALM BEACH FL 33480 DEBARMENT 1/5/2001
DEMASSI, MICHAEL A. LCSW 3/6/1969 1917 WATERS EDGE DRIVE TOMS RIVER NJ 08753 DISQUALIFICATION 12/20/2013
DEMEO, ROBERT MD 5/12/1945 1043220262 522 TYSENS LANE, 2ND FL. STATEN ISLAND NY 10306 DISQUALIFICATION 2/23/2015
DEMOSS, KATHLEEN M. DC 7/8/1967 14 N. MAIN STREET FLEMINGTON NJ 08822 SUSPENSION 6/19/2001
DENNIS, MOSES LPN 5/19/1981 625 GREENWAY AVENUE DARBY PA 19023 DISQUALIFICATION 6/18/2018
DENUCCI, NICHOLAS 7/22/1965 51 BARN OWL HACKETTSTOWN NJ 07840 DISQUALIFICATION 7/24/2002
DEORIO, ANA G. RN 10/3/1974 COLUMBIA AVENUE NORTH BERGEN NJ 07047 SUSPENSION 10/18/2007
DERRICK, NAOMI K. RN 5/5/1975 6 ENGLISH IVY DRIVE SICKLERVILLE NJ 08081 DISQUALIFICATION 12/26/2016
DESAI, BAKUL MD 12/29/1952 1376654624 15 MOUNTAIN RIDGE DRIVE LIVINGSTON NJ 07039 SUSPENSION 3/8/2010
DESAI, BAKUL MD 12/29/1952 1376654624 15 MOUNTAIN RIDGE DRIVE LIVINGSTON NJ 07039 DISQUALIFICATION 9/20/2012
DESANTIS, ANTHONY C. RPH 2/18/1926 105 FRANKLIN STREET BELLEVILLE NJ 07109 DEBARMENT 2/24/2003
DESIMONE, EUGENE MD 10/25/1953 1427098268 FCI FORT DIX, PO BOX 2000 JOINT BASE MDL NJ 08640 DISQUALIFICATION 10/28/2015
DESIR, MELISSA CHHA 6/24/1989 20 WILLOW DRIVE, APT. 8 OCEAN NJ 07712 DISQUALIFICATION 4/18/2017
DESTASIO, VINCENT MD 8/20/1961 1043215650 1851 HOOPER AVENUE TOMS RIVER NJ 08753 SUSPENSION 4/12/2016 5/13/2016
DESTASIO, VINCENT MD 8/20/1961 1043215650 1851 HOOPER AVENUE TOMS RIVER NJ 08753 DEBARMENT 5/13/2016
DETROLIO, DANIEL RN 7/13/1981 23 FOXWOOD DRIVE, APT. D MORRIS PLAINS NJ 07950 DISQUALIFICATION 3/27/2018
DEVARIS, HELENA D. DMD 8/8/1955 1679723589 35-08 MORLOT AVENUE 1X FAIR LAWN NJ 07410 SUSPENSION 5/21/2013
DEVARSO, ANGELA RN 8/15/1976 FCI DANBURY, RTE 37 DANBURY CT 06811 DEBARMENT 5/20/2012
DEVERA, MONICA T. 5/4/1945 118 BEACON STREET DUMONT NJ 07628 SUSPENSION 8/20/2002
DEVLIN, MARYELLEN RN 1/21/1959 809 DEVON ROAD RIVERSIDE NJ 08075 DISQUALIFICATION 6/4/2018 PERMANENT
DEZENHALL, MERVIN RPH 11/27/1930 SUNSET RD AT SUMMIT TURN WILLINGBORO NJ 08046 DISQUALIFICATION 6/1/1993
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
35
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DI SPALTRO, FRANKLIN L. MD 5/28/1940 1740627082 MELROSE LANE GREEN VILLAGE NJ 07935 SUSPENSION 10/18/2007
DIAZ, PEDRO P. 1/18/1930 80 SKYTOP RD. NEWTON NJ 07860 DISQUALIFICATION 5/20/2011
DIAZ-PELLOT, NORMA 10/31/1959 500 BERKELY DRIVE BROWNS MILLS NJ 08015 DISQUALIFICATION 3/24/2000
DIAZ-PELLOT, NORMA 10/31/1959 258 UNIVERSITY AVENUE PEMBERTON NJ 08068 DISQUALIFICATION 7/19/2001
DICARLO, ANTHONY G. 12/21/1936 35 GALT OCEAN DR FT LAUDERDALE FL 33308 DISQUALIFICATION 6/1/1993
DICICCO, RICHARD DC 9/28/1963 1073668265 1 MYERS AVENUE BERLIN NJ 08009 DISQUALIFICATION 6/5/2017
DICK, SHONDELL CHHA 4/29/1992 196 22ND STREET IRVINGTON NJ 07111 DISQUALIFICATION 1/29/2018 PERMANENT
DICKERSON, DENISE M. RN 6/12/1954 126 HILLCREST AVENUE, 2A BLACKWOOD NJ 08012 DISQUALIFICATION 9/22/2010
DICOVSKIY, CLAUDIO MD 6/22/1962 1932282845 1308 ABBOTT BOULEVARD FORT LEE NJ 07024 DISQUALIFICATION 8/7/2017
DICOVSKIY, CLAUDIO MD 6/22/1962 1932282845 1308 ABBOTT BOULEVARD FORT LEE NJ 07024 DISQUALIFICATION 2/23/2015
DICUBELLIS, MICHELE R. LCSW 4/8/1954 4030 ANDERSON AVENUE, SE ALBUQUERQUE NM 87108 DISQUALIFICATION 6/23/2011 10/22/2014
DIEM, MICHELLE C. CHHA 4/18/1990 821 NEVILLE STREET TOMS RIVER NJ 08753 DEBARMENT 9/23/2014
DIETERLE, KAREN M. RN 5/31/1960 51 STURBRIDGE DRIVE SICKLERVILLE NJ 08081 SUSPENSION 8/19/2004
DIETRICH, LISA B. 4/2/1967 DOGWOOD TRAIL RANDOLPH NJ 07869 SUSPENSION 11/20/2008
DIETZ, MICHAEL CHHA 2/1/1989 1602 AQUEDUCT COURT TOMS RIVER NJ 08755 DISQUALIFICATION 2/20/2017
DIGIORGIO, DAWN K. 10/16/1967 13 EAST PINE ST. 13D WESTVIEW NJ 08093 SUSPENSION 2/19/2004
DILLARD, LATICIA 3/5/1977 4208 NORTH DRIVE ATLANTIC CITY NJ 08401 DEBARMENT 8/24/2013
DILLIGARD, LATASHA CHHA 10/24/1991 320 W. BRANCH AVENUE,
APT. 47C
CAMDEN NJ 08021 DISQUALIFICATION 2/8/2017
DILORENZO, PAUL MD 2/7/1954 1699841056 22 NORTHWOODS ROAD OCEAN NJ 07712 DISQUALIFICATION 4/17/2017
DILUIGI, KENNETH RN 11/21/1958 RAVENSWOOD WAY SEWELL NJ 08080 DEBARMENT 12/17/2008
DIMEO, ALEXANDER 5/22/1984 19355 LASERNA DRIVE FORT MEYERS FL 33967 DISQUALIFICATION 3/3/2017
DINKEL, ARTHUR R. LCSW 11/9/1945 2 FREEMAN LANE DENVILLE NJ 07834 DEBARMENT 9/29/2000
DINKEL, ARTHUR R. LCSW 11/9/1945 2 FREEMAN LANE DENVILLE NJ 07834 DISQUALIFICATION 4/19/2001
DIRENZO, ALFRED M. DO 11/3/1934 167 GROVE STREET LODI NJ 07644 DISQUALIFICATION 2/21/1995
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
36
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DISCENZA, RONALD MD 6/21/1954 1528137882 2578 WOLF HOLLOW ROAD ANDES NY 13731 DISQUALIFICATION 4/17/2017
DITA, INC. 500 ORANGE STREET NEWARK NJ 07104 SUSPENSION 2/18/1998
DITURO, JOSEPH MD 3/2/1952 1194871459 376 WOOD RIDGE AVENUE WOOD RIDGE NJ 07075 DEBARMENT 2/15/2016
DIXIT, DIVY R. RPH 8/25/1969 1619125135 3022 EDWARD STEC BLVD EDISON NJ 08837 DISQUALIFICATION 4/30/2015
DIXON, SHANNON 2/11/1984 501 IRVING STREET CLEMENTON NJ 08021 DEBARMENT 3/18/2010 3/18/2013
DJAMBA, MONDJA CHHA 4/2/1987 17 PHEASANT ROAD CLEMENTON NJ 08021 DISQUALIFICATION 12/6/2017 PERMANENT
DJAVID, ISMAIL F. 4/10/1908 160 EAST 89TH STREET NEW YORK CITY NY 10028 DISQUALIFICATION
DOBROWOLSKI, DONALD DMD 6/17/1955 1184764664 45 BRICK BLVD. S-108 BRICK NJ 08723 DISQUALIFICATION 12/29/1995
DOLINER, PAUL MD 12/3/1927 401 US HIGHWAY 22 N. PLAINFIELD NJ 07060 DISQUALIFICATION 9/15/1980
DOMINIC JR., ANTHONY J. MD 4/27/1951 216 2ND AVENUE UPPER
MANASQUAN
NJ 08736 SUSPENSION 1/20/2002
DONALDSON, DENISE MD 1/26/1958 53 3RD AVENUE TOMS RIVER NJ 08757 DISQUALIFICATION 7/9/2003 DECEASED
DONALDSON, DENISE MD 1/26/1958 2650 SPRUCE DRIVE LAKEHURST NJ 08733 DISQUALIFICATION 12/29/1995 DECEASED
DONOFRIO, CHRISTINE RN 8/14/1965 207 TULIP LANE FREEHOLD NJ 07728 DISQUALIFICATION 8/3/2017
DONOFRIO, DOUG 8/11/1965 1 SPRING LAKE DRIVE FAR HILLS NJ 07931 DISQUALIFICATION 1/4/2012
DOOLEY, CHRISTOPHER J. PHD 9/6/1950 10 DEER RUN FREEHOLD NJ 07728 SUSPENSION 2/9/2009
DORBOR, BONGO CHHA 4/1/1977 2341 LIBERTY STREET HAMILTON NJ 08629 DISQUALIFICATION 2/20/2017
DORIA, LAWRENCE RPH 4/26/1937 6 BROOK PLAZA JACKSON NJ 08527 DISQUALIFICATION 2/7/1984
DORVIL, FAUBERT RN 3/5/1962 651 S. PALM STREET, #201 LITTLE ROCK AR 72205 DISQUALIFICATION 7/4/2014
DOSHI, PRIYAKANT S. MD 3/4/1942 11 WARFIELD STREET MONTCLAIR NJ 08625 DISQUALIFICATION 12/2/1997 DECEASED
DOSSEN, SEBRENA CHHA 9/9/1990 24 PHILLIP E. FRANK WAY CLIFFWOOD NJ 07721 DISQUALIFICATION 1/29/2018
DOSSOUS, JONAS CHHA 2/2/1977 1927 BANGS AVENUE NEPTUNE NJ 07753 DISQUALIFICATION 10/17/2017
DOTOLI, FRANKLIN MD 7/1/1924 460 FRANKLIN AVENUE NUTLEY NJ 07110 DISQUALIFICATION 6/1/1993 DECEASED
D'OTTAVIO, PAOLA RPH 8/29/1966 504 WILLOW OAK DRIVE MAYS LANDING NJ 08330 SUSPENSION 6/4/2007
D'OTTAVIO, PAOLA RPH 8/26/1966 504 WILLOW OAK DRIVE MAYS LANDING NJ 08330 DISQUALIFICATION 9/20/2011
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
37
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
DOUGHERTY-PRICE, ANITA
JO
CHHA 3/31/1954 212 WESTMONT AVENUE WESTMONT NJ 08108 DISQUALIFICATION 5/22/2017
DOWNTOWN DENTAL
CENTER
1 WEST BROADWAY PATERSON NJ DISQUALIFICATION 2/20/2001
DOYLE, JUDITH M. RN 11/15/1969 71 WILDFLOWER LANE MORRISTOWN NJ 07960 DEBARMENT 10/20/2004
DRIVAS, GUSTAVE S. MD 6/19/1955 1003867730 FCI LORETTO LORETTO PA 15940 DISQUALIFICATION 5/11/2014
DRIZAN, LOULEA CHHA 12/27/1978 43B MANLAY MANOR ELIZABETH NJ 07202 DISQUALIFICATION 3/6/2018
DUAH, GLORIA CHHA 7/7/1986 68 MYRTLE AVENUE IRVINGTON NJ 07111 DEBARMENT 2/20/2017
DUBNOFF, MICHELLE DC 8/4/1969 1225066210 333 PROVINCIAL DRIVE MORGANVILLE NJ 07751 DISQUALIFICATION 6/20/2018
DUBOVY, CARL MD 6/28/1933 11 PIPPINS WAY MORRISTOWN NJ 07960 DISQUALIFICATION 12/1/1998
DUCHEINE, YVAN MD 6/16/1963 1578638136 310 CENTRAL AVENUE EAST ORANGE NJ 07018 DEBARMENT 11/1/2017 4/5/2018
DUFF, RICHARD W. RN 3/8/1966 1260 SUMMERLEA AVENUE WASHINGTON PA 15301 DISQUALIFICATION 12/29/2015
DUFFIELD, CAMI R. RN 8/27/1970 119 GRAF AVENUE LAWRENCEVILLE NJ 08648 SUSPENSION 12/20/2000
DULL, JOHN W. DDS 1/11/1955 399 HOOVER AVENUE BLOOMFIELD NJ 07003 DISQUALIFICATION 12/1/1998 DECEASED
DUMITRU, DAN MD 11/27/1970 1073639530 1657 JFK BOULEVARD, FL 1 JERSEY CITY NJ 07305 DEBARMENT 1/11/2016
DUQUE, IRMA CHHA 12/19/1949 314 BROADWAY ELIZABETH NJ 07206 SUSPENSION 5/14/2007
DURFEE, JANET RN 1/31/1953 103 WOODLAKE DRIVE MARLTON NJ 08053 SUSPENSION 7/20/2004
DURIVAGE, SHARON RN/APN 7/14/1963 1407033442 1655 HUNTERS COURT YARDLEY PA 19067 DISQUALIFICATION 6/4/2018
DURNIEN, EDWARD CHHA 12/21/1971 215 CREEK RD. KEANSBURG NJ 07734 DISQUALIFICATION 1/6/2006
DURST, LAWRENCE RPH 1/1/1950 FCI FORT DIX, PO BOX 38 FORT DIX NJ 08640 SUSPENSION 6/19/2001
DYEVICH, KEVIN J. 1/16/1962 193 LIVINGSTON AVENUE NEW BRUNSWICK NJ 08901 DISQUALIFICATION 8/21/1996
DYOUS, KEISHA LPN 1/8/1972 2 BONNIE COURT LAWRENCEVILLE NJ 08648 DISQUALIFICATION 4/24/2018
DZIENISIEWSKI, DONNA J. RN 11/22/1973 9 IVY LANE MIDDLETOWN NJ 07748 DISQUALIFICATION 6/3/2016
DZUIK, CAROL CHHA 2/23/1958 416 CABLE AVENUE BEACHWOOD NJ 08722 DISQUALIFICATION 2/8/2017
EASTBURN, NORMAN W. DC 10/21/1965 1013056670 424 MATTHEWS LANE JACKSON NJ 08527 DISQUALIFICATION 11/14/2014
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
38
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
EASY DENTAL PC 1093093585 5616 GERMANTOWN AVENUE PHILADELPHIA PA 19114 DISQUALIFICATION 11/20/2015
EATOUGH, PHILIP DO 1/15/1947 1972681674 5 SYCAMORE LANE RUMSON NJ 07748 DISQUALIFICATION 2/26/2010
EDANIEWSKI, EDWARD R. 113 FRONT STREET SECAUCUS NJ 07094 DISQUALIFICATION
EDMILAO, CANUNITA 645 NEWARK AVENUE JERSEY CITY NJ 07305 SUSPENSION 4/9/2004
EDMONDS, KIANNAH CHHA 8/21/1994 916 4TH AVENUE WALL TOWNSHIP NJ 07719 DEBARMENT 12/6/2017
EGENBERG, IRIS 12/12/1955 153 AVENUE "B" BAYONNE NJ 07002 DISQUALIFICATION
EGLOFF, MARY ANN RN 7/9/1946 1100 KELLY LANE FARMINGDALE NJ 07727 SUSPENSION 5/19/2005
EIDMAN, STEVEN DDS 10/12/1956 73 E. LINCOLN AVENUE ENGLEWOOD NJ 07631 SUSPENSION 1/19/2003
EJIOFOR, UDOKA RN/APN 3/23/1963 1295096584/
1982024790
47 KENMORE AVENUE NEWARK NJ 07106 DEBARMENT 4/26/2018
EKSTEROWICZ, DEBORAH LPN 6/6/1954 283 S. BLACKHORSE PIKE MOUNT EPHRIAM NJ 08059 SUSPENSION 7/18/2002
ELAMIR, MAGDY MD 4/17/1953 1710081336 14 HIGH MEADOW RD. N SADDLE RIVER NJ 07458 DEBARMENT 3/18/2015
ELAMIR, MAGDY MD 4/17/1953 1710081336 550 SUMMIT AVENUE JERSEY CITY NJ 07306 DEBARMENT 11/5/2010
ELBASHIR, IMAD
MAHGOUB
1/1/1961 160 ALABAMA AVENUE PATERSON NJ 07505 SUSPENSION 1/28/2001
ELBASHIR, IMAD
MAHGOUB
1/1/1961 PO BOX 7450 TRENTON NJ 08628 SUSPENSION 6/17/2004
ELCHAGEA, ISMAIL 10/21/1951 470 CHAMBERLAIN AVENUE PATERSON NJ 07522 DEBARMENT 7/1/2000
ELHAG, ABUBAKER O. 1/19/1962 10 HILL STREET APT. 9W NEWARK NJ 07102 DEBARMENT 11/23/2007
ELIA, HARRY R. DC 5/11/1953 1104034578 136 BROADWAY WESTWOOD NJ 07675 DISQUALIFICATION 12/1/1998
ELIA-RAGGIO, LORI LPN 2/21/1961 4001 BURRYPORT WAY MOUNT LAUREL NJ 08054 SUSPENSION 3/18/2004
ELLIEN, WILLIAM MD 6/19/1955 1437196375 39 CABBAGE XING SAVANNAH GA 31411 DISQUALIFICATION 11/20/2015
ELLIOTT, CLAUDIA CHHA 5/3/1974 345 PARK AVENUE, APT. 4 PATERSON NJ 07504 DEBARMENT 9/26/2017
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
39
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ELLIS, KENT R. MD 12/1/1952 1005 N. WASHINGTON
AVENUE
GREEN BROOK NJ 08812 DEBARMENT 6/15/2001
ELLISON, RAEFORD LAC 10/19/1952 8 N. SACRAMENTO AVENUE VENTNOR NJ 08406 SUSPENSION 4/18/2002
EMERSON, BARBARA L. RN 9/6/1972 45 HAWTHORNE ST. BROWNS MILLS NJ 08015 SUSPENSION 5/20/2004
ENEMUO, JOHNNY 10/15/1966 215 JACOBY ST., 1ST FLOOR MAPLEWOOD NJ 07040 DISQUALIFICATION 5/1/1999
ENEMUO, KENNETH O. RPH 3/30/1962 236-242 S. ORANGE AVENUE NEWARK NJ 07103 DISQUALIFICATION 3/20/1999 10/26/2017
ENGRISSEI, PATRICIA LEISE RN 10/6/1953 700 GROVE STREET HADDONFIELD NJ 08033 SUSPENSION 8/18/2005
ENOGWE, FELIX RPH 3/25/1953 51 CLIFTON AVENUE, C-401 NEWARK NJ 07104 DISQUALIFICATION 5/24/1999
ENOGWE, FELIX RPH 3/25/1953 25 CLIFTON AVENUE NEWARK NJ 07104 DEBARMENT 2/24/2006
ENRICO JR., ANTHONY DPM 8/12/1957 1013095975 57 STONEYRIDGE DRIVE LINCOLN PARK NJ 07035 DISQUALIFICATION 5/2/2017
ENRICO JR., ANTHONY DPM 8/12/1957 1013095975 99 SUNCREST AVENUE NORTH HALEDON NJ 07508 DEBARMENT 2/8/2017
ERKOBONI, PATRICIA RN 6/25/1964 1850 W. MCGALLIARD
AVENUE
TRENTON NJ 08610 DISQUALIFICATION 5/14/2018
ERNST, DAVID J. DDS 7/7/1955 5 BRUNSWICK WOOD DRIVE E. BRUNSWICK NJ 08816 DISQUALIFICATION 3/31/1995
ESPADA, MARGARET CHHA 12/3/1976 310 HAMILTON AVENUE SEASIDE HEIGHTS NJ 08751 DISQUALIFICATION 2/8/2017
ESPINDOLA, JUAN MD 2/2/1958 1881703726 467 CLIFTON AVENUE CLIFTON NJ 07011 SUSPENSION 8/29/2016
ESPOSITO, VINCENT A. MD 12/19/1957 1225008253 5 BUCKINGHAM DRIVE MADISON NJ 07940 DISQUALIFICATION 7/20/2017
ESQUERRE, RENE MD 12/25/1951 1033150172 5 ASHLEY ROAD WEST ORANGE NJ 07052 DEBARMENT 7/18/2018
ESSER, ARISTIDE HENRI PSY 5/11/1930 1447249891 337 N. MAIN STREET STE 2 NEW CITY NY 10956 SUSPENSION 10/20/2013
ESTAMBUL, BERNARDO 11/10/1948 605 W. 141ST STREET, APT 51 NEW YORK NY 10031 DEBARMENT 1/31/2008
ESTERMAN, SIDNEY N. DPM 5/20/1932 185 CENTRAL AVENUE, STE.
412
EAST ORANGE NJ 07019 DISQUALIFICATION 8/31/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
40
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ETIENNE, FERNANDE CHHA 11/18/1963 1205 MORRIS STREET #2L ROSELLE NJ 07203 SUSPENSION 3/20/2006
EUSEBIO, EDWIN CHHA 4/3/1993 220 S. 30TH STREET CAMDEN NJ 08105 DISQUALIFICATION 1/31/2017
EVANS JR., EUGENE MD 7/26/1958 1033284930 301 EAST LINCOLN AVENUE ROSELLE PARK NJ 07204 DISQUALIFICATION 2/9/2017
EVANS, ROLAND A. DC 6/15/1967 263 NORTH 3RD AVENUE MANVILLE NJ 08835 DISQUALIFICATION 9/3/2003
EVDOKIMOW, DAVID MD 3/23/1960 1508930678 528 TEMPE WICK ROAD HARDING NJ 07960 DISQUALIFICATION 4/12/2018
EVRA, JOANEL CHHA 5/6/1986 1551B ASBURY AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 8/29/2017
EZELL, PAUL MD 2/28/1956 1235130741 251 SAGAMORE RD. HAVERTOWN PA 19083 DISQUALIFICATION 11/20/2015
EZEONYIM, CHARLES I. RPH 2/24/1961 2153 TYLER STREET UNION NJ 07083 DEBARMENT 1/16/2009 1/6/2012
FABULIAN, PETER DO 11/9/1947 1023184835 26 WEST MAIN STREET STRASBURG PA 17579 DISQUALIFICATION 2/20/2013
FAENZA, MATTHEW RPH 9/22/1938 64 COVENTRY WAY RINGWOOD NJ 07456 SUSPENSION 1/20/2004
FAERMAN, VLADIMIR CHHA 11/20/1947 2506 GATES COURT MORRIS PLAINS NJ 07950 DISQUALIFICATION 6/16/2017
FAHE, MIREILLE RN 5/3/1976 269 MAIN STREET, APT. B NEW MILFORD NJ 07646 DISQUALIFICATION 3/3/2017
FAISON, LAUREN 3/19/1973 1804 EAST THAYER STREET PHILADELPHIA PA 19134 DISQUALIFICATION 11/20/2015
FAKONDO, VICTOR H. RPH 10/19/1956 180 HANSON AVENUE PISCATAWAY NJ 08854 DISQUALIFICATION 8/18/2011
FALLAH, KEBEH CHHA 1/1/1994 365 SCHLEY STREET, APT. A8 NEWARK NJ 07112 DISQUALIFICATION 7/14/2017 6/12/2018
FALOWO, YETUNDE 2/16/1972 301 MAPLE AVENUE, APT266 N. PLAINFIELD NJ 07060 DISQUALIFICATION 1/6/2006
FAMILY ENRICHMENT
INSTITUTE
415 KEIM BOULEVARD BURLINGTON NJ 08016 SUSPENSION 8/20/1999
FARRIS, JOEL CHHA 10/30/1971 212 UNION AVENUE NEPTUNE NJ 07753 SUSPENSION 9/20/2001
FARRO, ANDREW 2/3/1961 87 CASTLE RIDGE DRIVE EAST HANOVER NJ 07936 SUSPENSION 6/12/2008
FASANO, JUDITH RN 1/25/1961 1770 YORKTOWNE BLVD. TOMS RIVER NJ 08753 DISQUALIFICATION 6/5/2017
FASWALA, MUNIR H. MD 3/20/1957 506 LAGOON BLVD. BRIGANTINE NJ 08203 DEBARMENT 9/15/2008
FASWALA, MUNIR H. MD 3/20/1957 506 LAGOON BLVD. BRIGANTINE NJ 08203 SUSPENSION 6/26/2005
FATATO, VIRGINIA A. DC 7/3/1960 1437432960 8 N. WHITEHORSE PIKE HAMMONTON NJ 08009 SUSPENSION 5/5/2003
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
41
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
FAULX, LORI RN 8/4/1966 4444 N 7TH AVENUE, APT.
417
PHOENIX AZ 85013 DISQUALIFICATION 11/20/2015
FAUSTINO, ALAN MD 4/18/1967 1669482568 110 WEST CHURCH STREET ABSECON NJ 08201 SUSPENSION 8/29/2016
FEE, CATHERINE ANN RPH 5/9/1965 7353 CLUBHOUSE CIRCLE EGG HARBOR CITY NJ 08215 SUSPENSION 10/19/2006
FEINBERG, IRA 411 CHELSEA STREET PARAMUS NJ 07652 DISQUALIFICATION 6/1/1993
FEINMAN, BRIAN DPM 4/29/1963 418 WALNUT STREET NEWARK NJ 07105 SUSPENSION 12/20/2006
FEIT, FREDRIC MD 5/29/1949 1093835308 2 TWIN LAKES DRIVE MANALAPAN NJ 07726 DEBARMENT 7/13/2009
FELDMAN, BRUCE J. 12/12/1948 807 NORTHWINDS DRIVE BRYN MAWR PA 19010 SUSPENSION 3/18/2004
FELDMON, DORON MD 5/25/1960 1194704627 FCI MCKEAN, PO BOX 8000 BRADFORD PA 16701 DISQUALIFICATION 12/29/2015
FELDNER, EDWARD S. MD 11/13/1955 50 E MAIN STREET LITTLE FALLS NJ 07424 DEBARMENT 11/16/1999 DECEASED
FELIX, JESSICA CHHA 4/7/1986 40 PASSAIC STREET, APT. 4D HACKENSACK NJ 07601 DISQUALIFICATION 8/14/2015
FELLUS, JONATHAN L. MD 6/9/1966 1053309195 57 WOODLAND AVENUE GLEN RIDGE NJ 07028 DISQUALIFICATION 8/20/2015
FELSENBERG, SANFORD 517 SO ORANGE AVENUE NEWARK NJ 07103 DISQUALIFICATION 6/1/1993
FERMIN, ESPERANZA CHHA 12/18/1981 229 MADISON AVENUE, APT.
1
PATERSON NJ 07524 DISQUALIFICATION 2/8/2017
FERNANDEZ, LUIS DPM 12/7/1965 293 MONROE STREET PASSAIC NJ 07055 SUSPENSION 3/26/1997
FERRANDINO, LUIGI MD 5/5/1923 8 EAST RAMAPO AVENUE MAHWAH NJ 07430 DISQUALIFICATION 5/20/2007 DECEASED
FERRARI, FRANCIS M. DPM 3/10/1947 482 KEARNEY AVENUE KEARNY NJ 07032 DISQUALIFICATION 2/16/1995
FERRINGO, MICHAEL J. 9/5/1979 616 GLEN COURT TURNERSVILLE NJ 08012 DISQUALIFICATION 6/20/2012
FERSTANDIG, RUSSELL A. MD 5/17/1949 1780779702 179 MAPLE AVENUE RIDGEWOOD NJ 07450 DISQUALIFICATION 12/7/1987 1/1/2013
FIELDS, CARENE CHHA 9/27/1970 190 HAMILTON AVENUE, APT.
#8
PATERSON NJ 07501 DISQUALIFICATION 2/20/2017
FIGUEROA, DESIREE CHHA 10/10/1992 11 COLLETON STREET LAKEWOOD NJ 08701 DISQUALIFICATION 2/20/2017
FIGUEROA, JORGE MD 7/15/1958 1770542151 493 21ST AVENUE PATERSON NJ 07513 DEBARMENT 1/23/2018
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
42
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
FIGUEROA, JORGE MD 7/15/1958 1770542151 USP-LEWISBURG, PO BOX
1000
LEWISBURG PA 17837 DISQUALIFICATION 4/19/2018
FILIPPONE JR., DENNIS R. MD 11/18/1957 147 STANTON RD. FLEMINGTON NJ 08822 DEBARMENT 11/21/1998
FINDER, RICHARD DC 6/12/1956 810 ABBOTT BLVD. FORT LEE NJ 07024 DEBARMENT 5/1/2004
FINE, EDWARD MD 10/24/1933 271 MOORE LANE HADDONFIELD NJ 08033 DISQUALIFICATION 9/28/1983
FINESMITH, ROSS MD 3/27/1961 PARKVIEW AVENUE BASKING RIDGE NJ 07920 DISQUALIFICATION 8/10/2007
FINE-TRANS MEDICAL
TRANS.
2824 KENNEDY BLVD. #465 JERSEY CITY NJ 07306 DISQUALIFICATION 6/14/1994
FINK, DAVID PSYCH 2/26/1928 139 HIGHLAND AVENUE METUCHEN NJ 08840 SUSPENSION 5/20/2003
FINKEL, MARINA 4/30/1963 75 STONEGATE DRIVE STATEN ISLAND NY 10304 DISQUALIFICATION 10/3/2013
FINKEL, MARINA 4/30/1963 EDNA MAHAN CORRECTIONAL CLINTON NJ 08809 DISQUALIFICATION 6/15/2014
FINLAY MEDICAL
LABORATORY
4912 BERGENLINE AVENUE WEST NEW YORK NJ 07093 DISQUALIFICATION 3/14/1998
FIRESPIRIT, INC. 6612 TERRA DOLCE AVENUE
NW
ALBUQUERQUE NM 87114 DISQUALIFICATION 6/23/2011
FISCHBERG, JUAN C. MD 10/6/1947 354 RUSSELL AVENUE EDGEWATER NJ 07020 SUSPENSION 6/19/2008
FISCHGRUND, JOEL MD 3/3/1953 1427097534 56 CORNELL DRIVE LIVINGSTON NJ 07039 DEBARMENT 8/30/2014
FISCHGRUND, JOEL MD 3/3/1953 1427097534 56 CORNELL DRIVE LIVINGSTON NJ 07039 DISQUALIFICATION 3/24/2017
FISCHMAN, HAROLD MD 6/3/1903 56 BOWDOIN STREET MAPLEWOOD NJ 07040 DISQUALIFICATION 6/1/1993
FISH, MICHAEL DMD 10/19/1977 1500 PINE PARK AVENUE LAKEWOOD NJ 08701 DEBARMENT 4/20/2007 7/17/2013
FISHER, CALLETTA PHARM
TECH
5/16/1996 115 SENECA BOULEVARD BARNEGAT NJ 08005 DISQUALIFICATION 11/21/2016
FISHER, DARRYL 4/12/1968 55 SHELBOURNE STREET BURLINGTON NJ 08016 DISQUALIFICATION 3/6/2006
FLEISCHER, MARK H. MD 7/7/1948 PO BOX 600, FCI OTISVILLE NY 10963 SUSPENSION 4/20/2005
FLEISCHMAN, EDWARD DO 10/3/1928 3804 CHURCH RD. MOUNT HOLLY NJ 08054 SUSPENSION 8/25/1998
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
43
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
FLEMING, KEVIN M. MD 6/30/1954 1508816075 710 STATION AVENUE, 2ND
FLR
HADDON HEIGHTS NJ 08035 SUSPENSION 11/20/2010
FLEURANTIN, RUBEN J. MD 11/20/1951 SCOTLAND RD. SO. ORANGE NJ 07079 SUSPENSION 3/20/2008
FLEURY, DIANE RN 2/22/1951 552 PENNY STREET FRANKLINVILLE NJ 08322 SUSPENSION 5/20/2001
FLORES, CARMEN CHHA 10/25/1975 95 PROSPECT STREET, APT. #1 PASSAIC NJ 07055 DISQUALIFICATION 3/6/2018
FLORES, MARIE MIRAVITE RN 2/15/1957 258 DEEP BROOK COURT PISCATAWAY NJ 08854 DEBARMENT 9/20/2004
FLORES, MELBA CHHA 11/17/1969 106 MAPLE AVENUE BOONTON NJ 07005 DISQUALIFICATION 2/20/2017
FLOUNDERS, JOSEPH P. LPN 11/3/1968 106 W. MIAMI AVENUE VILLAS NJ 08251 SUSPENSION 10/20/2005
FLOWERS JR., HERMAN J. CHHA 10/30/1964 143 URSINUS COURT PEMBERTON NJ 08075 DISQUALIFICATION 12/10/1997
FLOWERS, FELICIA CHHA 7/11/1977 321 NEPTUNE BOULEVARD NEPTUNE NJ 07753 DISQUALIFICATION 7/14/2017
FLOWERS, HERMAN T. 143 URSINUS COURT PEMBERTON NJ 08075 SUSPENSION 3/16/1999
FLOYD, JAMES PHD 3/25/1947 1733 BLAKE BOTTOM RD. NW HUNTSVILLE AL 35806 DISQUALIFICATION 2/26/2010
FOGLER, SEAN MD 10/8/1968 1548322068 1900 HAMILTON STREET PHILADELPHIA PA 19130 DISQUALIFICATION 8/28/2017
FOLK, THOMASA A. 2/3/1960 463 IRVINGTON AVENUE ELIZABETH NJ 07201 DISQUALIFICATION 3/19/2006
FOLKERTS, ANNAMARIA MD 8/24/1961 32 OAK PLACE HAWTHORNE NJ 07506 DISQUALIFICATION 12/8/1993
FONTANELLA, DANIEL DC 10/16/1964 27 MOUNTAINWOOD COURT TOTOWA NJ 07512 SUSPENSION 11/20/2003
FONTANEZ, MODESTO MD 1/4/1948 1851395826 1838 2ND AVENUE NEW YORK NY 10128 DISQUALIFICATION 10/7/2011
FORBES, AASE RN 4/5/1967 882 DEWEY STREET UNION NJ 07083 DISQUALIFICATION 4/20/2009
FORDE, SHIVONNE 11/24/1982 57 CHESTNUT STREET C4 EAST ORANGE NJ 07018 DISQUALIFICATION 3/8/2010 3/8/2015
FORMAN, STEVE DPM 5/10/1957 1700850096 15 CANTERBURY PLACE SICKLERVILLE NJ 08081 DEBARMENT 4/18/2017
FORNEY, DONALD 6/20/1967 354 CRESCENT STREET HARRISBURG PA 17104 DISQUALIFICATION 11/20/2015
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
44
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
FORSHAY, LAUREN RN 1/12/1977 2201 RIVER ROAD PT. PLEASANT BORO NJ 08742 DISQUALIFICATION 10/25/2016 6/26/2017
FORTI, PAUL J. PSYCH 6/24/1949 6 SILVER SPRING COURT EAST HANOVER NJ 07936 DISQUALIFICATION 7/19/2001
FORTUNATO, FRANKLIN MD 12/31/1949 1548278930 FMC - DEVENS, PO BOX 879 AYER MA 01432 DISQUALIFICATION 2/11/2016
FORTUNATO, FRANKLIN MD 12/31/1949 1548278930 127 PINE STREET MONTCLAIR NJ 07042 DISQUALIFICATION 6/29/2015
FOSTER, DEBRA CHHA 1/11/1995 714 ZLOTKIN CIRCLE, APT. 6 FREEHOLD NJ 07728 DISQUALIFICATION 4/18/2017
FOWLER, BERNARD J. MD 3/24/1945 1326105032 15 GRIST MILL RUN MAHWAH NJ 07430 DISQUALIFICATION 3/27/2014
FOWLER, BERNARD J. MD 3/24/1945 1326105032 1341 MIDDLE GULF DRIVE
12D
SANIBEL FL 33957 DISQUALIFICATION 8/20/2015
FOX, SUSAN DMD 12/28/1979 1952661472 2300 WALNUT STREET PHILADELPHIA PA 19103 DISQUALIFICATION 12/29/2015
FRAENKEL, DAVID M. DDS 12/7/1957 1790774271 BERGEN MALL DENTAL OFFICE PARAMUS NJ 07652 DISQUALIFICATION 11/4/1991 4/5/2018
FRANCILLON. CARLINE LPN 7/23/1985 98 ASHLAND AVENUE, 2ND
FLOOR
WEST ORANGE NJ 07052 DEBARMENT 11/13/2017
FRANCO, DAISY CHHA 9/5/1973 URB JARDIN DE S. ANNA COAMO PR 00769 DISQUALIFICATION 8/10/2007
FRANCOIS, EMMANUEL MD 5/4/1954 1457383382 187 HOBART GAP ROAD LIVINGSTON NJ 07039 DISQUALIFICATION 10/10/2016
FRANCOIS, ESTHER CHHA 9/21/1986 514 LIDGERWOOD AVENUE ELIZABETH NJ 07202 DISQUALIFICATION 1/17/2018
FRANK, OLEG MD 1/22/1971 1457469090 40 FERRY STREET NEWARK NJ 07105 DEBARMENT 9/9/2016
FRANKLIN MEDICAL
ASSOCIATES
14 FRANKLIN STREET BELLEVILLE NJ DISQUALIFICATION 10/15/1999
FRARE, ROBERT DMD 9/16/1964 1740477553 15 PROMENADE PLACE VOORHEES NJ 08043 DISQUALIFICATION 8/29/2014
FRASCA, CLIFFORD C. 5/22/1961 637 WESTON DRIVE TOMS RIVER NJ 08755 SUSPENSION 4/8/1999
FRASER, KEITH MD 7/25/1957 1881621266 6 WEDGEWOOD DRIVE, UNIT
7
VERONA NJ 07044 DISQUALIFICATION 1/10/2011 12/4/2014
FRASER, SHAWN E. 1/1/1969 PO BOX 7000 FORT DIX NJ 08640 SUSPENSION 10/20/2005
FREDERICK, KIMBERLY M. RN 8/21/1966 78 BOUNDARY AVENUE HANOVER PA 17331 DEBARMENT 9/12/2008
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
45
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
FREE, KEVIN R. MD 12/13/1955 14 PATTEN TERRACE CEDAR GROVE NJ 07009 DISQUALIFICATION 7/14/1998
FRENCH, EUGENE MD 10/22/1959 1215927843 241 SUMMIT AVENUE HACKENSACK NJ 07601 DEBARMENT 4/18/2016
FRICK, JAEMS 10/17/1959 1626 ABBOT AVENUE TOMS RIVER NJ 08753 DISQUALIFICATION 5/5/2004
FRIDMAN, LEV CHHA 7/12/1941 6 SALT MEADOW ROAD EAST BRUNSWICK NJ 08816 DEBARMENT 5/2/2017
FRIEDMAN, AMIR MD 6/30/1968 1417907361 390 N. BROADWAY, STE 1000 PENNSVILLE NJ 08070 DEBARMENT 8/1/2014 8/11/2016
FRIEDMAN, LAWRENCE A. 10/1/1947 1688-90 54TH STREET BROOKLYN NY 11024 DISQUALIFICATION 6/16/2002
FRIEDMAN, SHERRY RN 1/11/1968 12 HOPI TRAIL OAK RIDGE NJ 07348 SUSPENSION 9/19/2003
FRIEND, CHARLES LPN 6/18/1955 2336 CORBETT RD PENNSAUKEN NJ 08109 SUSPENSION 6/19/2003
FRIMPONG, JOSEPH CHHA 3/2/1948 357-363 LINCOLN AVENUE,
APT. 3D
ORANGE NJ 07050 DISQUALIFICATION 1/31/2017
FRIMPONG, KOFI LPN/RN 7/23/1951 ESSEX RD. MAPLEWOOD NJ 07040 DEBARMENT 12/20/2007
FRISCH, FREDERICK MD 5/10/1917 7 SOUTH DUDLEY AVENUE VENTNOR NJ 08406 DISQUALIFICATION 3/5/1994 DECEASED
FRITTS, LARRY F. RN 5/15/1965 5 AUTUMN RIDGE LANE PHILLIPSBURG NJ 08865 SUSPENSION 6/20/2005
FRITZ, GINA LPN 2/24/1963 52718-2 PIMA COURT KILEEN TX 76543 DISQUALIFICATION 5/14/2018
FROHWIRTH, DANIEL H. MD 6/6/1947 MEADOW RD, PO BOX 274 WHITEHOUSE NJ 08888 DISQUALIFICATION 4/18/1992
FROMER, CARL H. MD 4/25/1950 1000 CLOVER RD., APT. 7R STATEN ISLAND NY 10314 DISQUALIFICATION 6/20/2000
FROMM, JOSEPH MICHAEL 10/29/1947 28301 ATLANTIC AVENUE
#110 S
ATLANTIC CITY NJ 08401 DISQUALIFICATION 3/17/1991
FRYE, ROBIN CHHA 7/19/1963 1224 WASHINGTON AVENUE CAMDEN NJ 08104 DISQUALIFICATION 2/13/2018 PERMANENT
FRYER, CYNTHIA LPN 12/8/1967 PO BOX 121 MERRY HILL NC 27957 DISQUALIFICATION 12/29/2017
FURLONG, KELLY AKA
COPPOLA, KELLY
PHARM
TECH
3/21/1985 52 CORNELL DRIVE HAZLET NJ 07730 DISQUALIFICATION 9/23/2016
GABER, ROBERT A. DDS 11/13/1947 100 VAIL RD. PARSIPPANY NJ 07054 DISQUALIFICATION 12/19/1988
GABRIEL, NWALA RPH 7/7/1960 34 SCHOOL STREET PISCATAWAY NJ 08854 DISQUALIFICATION 2/23/2010
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
46
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GADHOK, RAJINDER S. 8/9/1937 120 CIRCEL AVENUE, BOX 121 BERKELEY HEIGHTS NJ 07922 DISQUALIFICATION 8/12/1997
GAFFNEY, JOHN DO 4/7/1962 1710985387 9501 VENTNOR AVENUE MARGATE CITY NJ 08402 DISQUALIFICATION 7/24/2017
GAINER, JAHNIA PHARM
TECH
11/29/1992 176 AVON AVENUE. APT. 4A NEWARK NJ 07108 DEBARMENT 4/26/2016
GAINES, TONI 8/3/1974 4650 COLES MILL RD. R-3 WILLIAMSTOWN NJ 08094 DISQUALIFICATION 8/4/2012 8/3/2014
GAITHER, HERBERT MD 11/21/1936 1453 HILLCREST COURT, APT.
407
CAMP HILL PA 17011 DISQUALIFICATION 11/20/2015
GALCIK, DIANE LPN 8/9/1955 34 MAHAN STREET TENAFLY NJ 07670 SUSPENSION 8/20/2001
GALIN, MILES A. MD 1/6/1932 EAST END AVENUE NEW YORK NY 10128 DEBARMENT 9/19/2008
GALINSKY, KIMBERLY RPH 5/23/1989 220 VAN FLEET AVENUE SOUTH PLAINFIELD NJ 07080 DISQUALIFICATION 8/10/2017
GALINSKY, RONALD C. PSYCH 8/13/1941 34 DUNHILL DRIVE VOORHEES NJ 08043 DISQUALIFICATION 12/1/1998
GALL, WILLIAM J. DO 4/4/1943 22 STONEGATE COURT BLACKWOOD NJ 08012 DISQUALIFICATION 7/20/2009
GALLAGHER JR., WALTER B. RN 9/19/1950 132 TULIP LANE SUMMIT NJ 07901 SUSPENSION 9/20/2005
GALLAGHER, BRENDA JO RN/LPN 5/4/1955 14B WISHING WELL RD. HAMBURG NJ 07419 SUSPENSION 4/19/2001
GALLAGHER, JOANNE M. DC 9/23/1959 108 BENJAMIN AVENUE CONYNGHAM PA 18219 SUSPENSION 10/20/2005
GALLAGHER, PATRICIA A. RN 4/3/1986 111 QUAKER RD. MICKLETON NJ 08056 DISQUALIFICATION 8/20/2014
GALLE, JAMES RPH 5/8/1946 105 ELM AVENUE HACKENSACK NJ 07644 DISQUALIFICATION 9/16/2003
GALLETTA, ERNEST 3/16/1949 FCI FAIRTON, PO BOX 420 FAIRTON NJ 08320 SUSPENSION 2/19/2009
GALLETTA, GEORGE W. 4/13/1952 3001 E. CHESTNUT AVENUE
A1
VINELAND NJ 08361 DISQUALIFICATION 2/19/2009
GAMAO, EDDIE MD 6/2/1940 1639479397 375 NORTH DRIVE J9 NORTH PLAINFIELD NJ 07060 DISQUALIFICATION 3/14/2018
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
47
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GANDHI, HIREN 2/15/1962 120 ROLLING BROOK DRIVE EDISON NJ 08820 SUSPENSION 10/20/2005
GANETSKY, SVETLANA PT 5/25/1977 1407180037 197 EDWARDS DRIVE SOUTHAMPTON PA 18966 DISQUALIFICATION 11/20/2015
GANTI, SHASHI MD 3/15/1954 2035 HAMBURG PIKE WAYNE NJ 07410 DISQUALIFICATION 8/20/1997
GARCEN, GINA AKA
CIALLELLA, GINA
DC 4/14/1962 57 GREEN STREET WOODBRIDGE NJ 07095 DISQUALIFICATION 3/24/2000
GARCIA, DIANE LCSW 12/3/1947 6612 TERRA DOLCE AVENUE
NW
ALBUQUERQUE NM 87114 DISQUALIFICATION 1/18/2012
GARCIA, SHEILA CHHA 3/2/1995 1003 W. CHAPLAIN ROAD MANVILLE NJ 08836 DISQUALIFICATION 5/2/2017
GARDINER, MICHAEL, A. DC 12/27/1952 1346524907 2066 MILBURN AVENUE MAPLEWOOD NJ 07040 SUSPENSION 2/3/2003
GARIPALLI, LAXMIPATHI MD 10/22/1949 1851325500 11 COLTS GAIT LANE COLTS NECK NJ 07722 SUSPENSION 4/21/2008
GARIPALLI, LAXMIPATHI MD 10/22/1949 1851325500 11 COLTS GAIT LANE COLTS NECK NJ 07722 DISQUALIFICATION 9/20/2012
GARRETSON, MATTHEW PHARM
TECH
3/10/1990 119 GLEN AVENUE LAKEWOOD NJ 08701 DISQUALIFICATION 9/23/2016
GARRITANO, RALPH E. MD 9/12/1924 281 GROVE ST ORADELL NJ 07649 DISQUALIFICATION 6/1/1993
GAULT, TYMIER CHHA 4/12/1990 180 HAYNES AVENUE BRIDGETON NJ 08302 DEBARMENT 7/22/2017
GAYLE, DELORES MD 10/11/1940 1508886664 249 GREGORY AVENUE WEST ORANGE NJ 07052 DEBARMENT 12/16/2015 6/5/2017
GAYLE, DELORES MD 10/11/1940 1508886664 249 GREGORY AVENUE WEST ORANGE NJ 07052 DISQUALIFICATION 6/5/2017 PERMANENT
GAYLE, LURINE CHHA 2/15/1961 2144 ALDRIN ROAD, #5A OCEAN NJ 07712 DISQUALIFICATION 2/8/2017
GECYS, GINTARE T. DO 3/15/1961 1504 BLACKWOOD
CLEMENTON
BLACKWOOD NJ 08012 DEBARMENT 9/22/2015
GEFFEN, STEVEN 1/27/1957 50 SKYLARK COURT MARLBORO NJ 07746 DISQUALIFICATION 8/15/2000
GENNINGER, LEWIS E. MD 1/26/1916 95 SOUTH MAIN ST PHILLIPSBURG NJ 08865 DISQUALIFICATION 1/10/1988 DECEASED
GENSHEIMER, MAUREEN LPN 3/1/1957 1409 EDGEMERE RD. WALL NJ 07719 SUSPENSION 9/19/2002
GEORGE, JOBY RPH 5/14/1974 1255481917 395 MYRTLE STREET CLIFFWOOD NJ 07721 DEBARMENT 7/18/2011
GEORGIA LUNG
ASSOCIATES
1104989136 3820 MEDICAL PARK AVENUE AUSTELL GA 30106 DISQUALIFICATION 11/20/2015
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
48
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GERARDO, LETRICIA M. MD 6/4/1934 317 MT. PROSPECT AVENUE NEWARK NJ 07104 DISQUALIFICATION 5/30/1997
GERMAN, MARIA CHHA 6/17/1967 195 BROADWAY PATERSON NJ 07505 DEBARMENT 5/24/2002
GETSON, LEE 6/1/1952 7 HAMILTON COURT SOUTHAMPTON NJ 08088 DISQUALIFICATION 5/12/2016
GIACALONE-HEWSON,
MARIA
DC 9/14/1971 1487782504 FCI COLEMAN MEDIUM, PO
BOX 1032
COLEMAN FL 33521 DISQUALIFICATION 11/20/2015
GIALANELLA, CRAIG MD 10/28/1963 1467596502 4 OXFORD ROAD NORTH CALDWELL NJ 07006 DISQUALIFICATION 7/19/2017
GIANETTI JR., JOSEPH P. DC 12/21/1956 LINDEMAN AVENUE CLOSTER NJ 07624 SUSPENSION 9/18/2008
GIANNOTTO, ANTHONY MD 12/26/1919 31 PALM STREET NEWARK NJ 07106 DISQUALIFICATION 11/24/1988
GIARRETTA, MARY
SUEANNE
RPH 1/19/1951 9 KINGWOOD AVENUE FRENCHTOWN NJ 08825 DISQUALIFICATION 2/15/2001
GIBBONS, SHANIKA CHHA 12/29/1986 11 LINDEN AVENUE EDISON NJ 08817 DISQUALIFICATION 1/31/2017
GIBBONS, SHAWN S. 2/7/1972 40 DOVER STREET NEWARK NJ 07106 DEBARMENT 11/24/2007
GIBBONS, WAYNE L. MD 12/10/1948 2 EAST RIVER DRIVE WILLINGBORO NJ 08046 DEBARMENT 1/12/2001
GIBBS, ARLENE CHHA 1/21/1976 35 CIVIC SQUARE, #23 IRVINGTON NJ 07111 DISQUALIFICATION 1/28/2006
GIBBS, ARLENE CHHA 1/21/1976 18 BELLEVILLE CT., APT C BELLEVILLE NJ 07109 DEBARMENT 5/20/2007
GIBBS, MARY ELLEN CHHA 4/22/1971 157 ANDREW STREET HAMILTON NJ 08610 SUSPENSION 2/14/2002
GIBNEY, EDWARD 10 CEDAR LAKE DENVILLE NJ 07834 DISQUALIFICATION 6/1/1993
GIBSON, MARY E. 1/20/1964 376 MADISON AVENUE RAHWAY NJ 07065 DISQUALIFICATION 7/18/2001
GIFFINS-MATLACK,
DEANNE
LPN 4/3/1985 46 BURT STREET BRIDGETON NJ 08302 DISQUALIFICATION 8/28/2017
GILL, ALYSON R. RN 8/8/1964 115 BRADLEY COURT LAUREL SPRINGS NJ 08021 SUSPENSION 6/19/2003
GILL, JEFFREY J. DPM 3/30/1954 1168 BEACON AVENUE MANAHAWKIN NJ 08050 DEBARMENT 9/13/1999
GILL, YURI CHHA 12/10/1984 13 PINE GLEN DRIVE SICKLERVILLE NJ 08081 DISQUALIFICATION 9/19/2017
GILLARD, MARY RN 8/18/1969 321 SUNSET AVENUE, APT. 2H ASBURY PARK NJ 07712 SUSPENSION 4/20/2003
GILLER, LEONID 9/4/1949 4 WOODFERN STREET EDISON NJ 08820 DEBARMENT 8/27/1999
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
49
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GILLIARD, MICHELLE CHHA 4/18/1978 2929 HURLEY POND ROAD WALL NJ 07719 DEBARMENT 1/20/2017
GILLISS, ADAM DO 1/31/1966 1982741328 27 EAST CHESTNUT AVENUE MERCHANTVILLE NJ 08109 DEBARMENT 12/16/2015
GILMAN, DANIEL 1/14/1953 FCI - FAIRTON, PO BOX 420 FAIRTON NJ 08320 DISQUALIFICATION 7/20/2017
GILMAN, DENISE DO 2/28/1977 1689986960 108 WOODCREST DRIVE CORAOPOLIS PA 15108 DISQUALIFICATION 11/20/2015 9/19/2016
GILMORE, BRUCE
STEWART
MD 10/23/1955 1306985882 FRANKLIN DRIVE ARDMORE OK 73401 SUSPENSION 9/18/2008
GILTMAN, JEROME RPH 4/18/1934 7320 VENTOR AVENUE VENTNOR NJ 08406 DISQUALIFICATION 4/30/2007
GITKIN, SAMUEL 9/1/1947 1288 15TH STREET FORT LEE NJ 07024 SUSPENSION 4/18/2002
GLASER, VICTORIA M. RN 10/7/1962 1612 THIRD STREET RENSSELAER NY 12144 SUSPENSION 7/18/2002
GLASS, JOEL MD 12/23/1942 1861537219 2027 SPRING GARDEN STREET PHILADELPHIA PA 19130 DISQUALIFICATION 6/28/2017 PERMANENT
GLASS, JOEL MD 12/23/1942 1861537219 2027 SPRING GARDEN STREET PHILADELPHIA PA 19130 DISQUALIFICATION 10/27/2017 PERMANENT
GLASS, MICHAEL R. PSYCH 7/3/1933 1345 SLATERVILLE RD. ITHACA NY 14850 DEBARMENT 1/18/2007
GODBOLT, KIMISHA CHHA 1/4/1983 190 HAMILTON AVENUE PATERSON NJ 07501 DEBARMENT 8/24/2017
GODWIN, LASTAISA PHARM
TECH
6/15/1993 6 HILLSIDE TERRACE SUSSEX NJ 07461 DISQUALIFICATION 2/1/2018
GOLDBERG, CHARLES S. MD 10/3/1953 1164443958 FCI-OTISVILLE, PO BOX 1000 OTISVILLE NY 10963 DISQUALIFICATION 1/22/2016
GOLDBERG, RICHARD MD 2/6/1950 1629136320 FEDERAL BUREAU PRISONS -
RRM #66231-050 100 29TH
STREET
BROOKLYN NY 11232 DISQUALIFICATION 2/9/2017
GOLDBERG, RICHARD MD 2/6/1950 1629136320 95 DAVIS HILL ROAD WESTPORT CT 06883 DEBARMENT 7/1/2015
GOLDSTEIN, JACK DO 3/28/1937 1154355055 695A MAIN STREET LUMBERTON NJ 08048 DEBARMENT 8/28/2014 DECEASED
GOLDSTEIN, JACK DO 3/28/1937 1154355055 695A MAIN STREET LUMBERTON NJ 08048 DISQUALIFICATION 11/20/2015 DECEASED
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
50
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GOLDTHWAITE, JENNIFER LPN 3/9/1979 507 KENBURY ROAD BRANCHBURG NJ 08876 DISQUALIFICATION 3/15/2018
GOLEJ, IVY RN 11/5/1973 631 MARION ROAD NEPTUNE NJ 07753 DISQUALIFICATION 9/9/2016
GOLIN, MARK W. MD 11/20/1941 172 FRANKLIN AVENUE, SUITE
4
RIDGEWOOD NJ 07450 SUSPENSION 3/20/2003
GOMEZ, ALFREDO CHHA 12/23/1965 148 NORTH 10TH STREET,
2ND FLOOR
PATERSON NJ 07522 DISQUALIFICATION 4/26/2018
GOMOLINSKI, NANCY LCSW 1/1/1953 1700986890 23 FORSHEE CIRCLE MONTVALE NJ 07645 DISQUALIFICATION 5/7/2014
GONSHERY, DENISE C. RPH 10/19/1963 900 MCELWEE RD. MOORESTOWN NJ 08057 SUSPENSION 2/20/2005
GONZALEZ, ARELIS CHHA 11/1/1985 28 MADOLE PLACE PENNS GROVE NJ 08069 DISQUALIFICATION 1/31/2017
GONZALEZ, FELICIA E. DO 9/11/1958 1598850935 1203 GREEN VIEW WAY TOMS RIVER NJ 08753 DEBARMENT 9/19/2011 6/17/2013
GONZALEZ, JORDAN RPH 2/14/1980 1992073167 #66214-050, FCI FAIRTON, PO
BOX 420
FAIRTON NJ 08320 DISQUALIFICATION 2/9/2017
GONZALEZ, LEAH CHHA 3/27/1993 5 TWIN RIVERS DRIVE EAST WINDSOR NJ 08520 DEBARMENT 1/16/2017
GONZOPH, BARBARA AKA
DUFFY, BARBARA
LPN 3/29/1964 208 WAYNE TERRACE COLLINGSWOOD NJ 08108 SUSPENSION 8/19/2004
GOOBERMAN, LANCE MD 12/8/1944 1194998682 1 SOUTH CENTRE STREET MERCHANTVILLE NJ 08109 SUSPENSION 2/24/2004 7/23/2012
GOODEY, KATHLEEN 7/13/1961 333 WHITTIER AVENUE DUNELLEN NJ 08812 SUSPENSION 5/23/1997
GOODIN, RICHARD C. MD 8/13/1943 RIVERVIEW CORRECTIONAL OGDENSBURG NY 13669 SUSPENSION 8/19/2004
GOODNIGHT, JAMES W. MD 12/11/1962 1144313131 535 HIGH MOUNTAIN RD. NORTH HALEDON NJ 07508 DEBARMENT 1/17/2014 4/11/2017
GOODWIN, BARBARA G. RN 2/23/1959 1201 NORTH CHARLOTTE ST. DICKSON TN 37055 SUSPENSION 12/19/2002
GORDON, BARBARA X-RAY
TECH
8/23/1963 133 MORTON AVENUE S. PLAINFIELD NJ 07080 DISQUALIFICATION 4/5/2001
GORDON, CRAIG W. MD 9/27/1957 164 RIVEREDGE DRIVE CHATHAM NJ 07928 DISQUALIFICATION 9/4/2007
GORDON, CRAIG W. MD 9/27/1957 8 SHERWOOD CIRCLE LINDEN NJ 07036 DISQUALIFICATION 3/18/1993
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
51
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GORDON, HOWARD L. MD 2/15/1926 222 BROADWAY NEWARK NJ 07104 DISQUALIFICATION 6/1/1993
GORDON, RAHSHEEDA CHHA 3/3/1979 445 SOUTH 11TH STREET NEWARK NJ 07103 DISQUALIFICATION 2/8/2017
GORIGANTI, MAHENDER MD 9/19/1959 1144202805 7187 WOODCHUCK HILL RD. FAYETTEVILLE NY 13066 DISQUALIFICATION 7/20/2015
GOROVITS, LILIA MD 4/20/1958 1427163427 1157 METTLER ROAD HUNTINGTON
VALLEY
PA 19006 DISQUALIFICATION 8/7/2017
GOTAY, ALEXANDER LCSW 8/26/1961 SSCF, PO BOX 150 DELMONT NJ 08314 DISQUALIFICATION 2/24/2008
GOULBOURNE, MARIANA CHHA 6/19/1964 430 S. 13TH STREET NEWARK NJ 07103 DISQUALIFICATION 3/6/2018
GRANGER, MAI AKA
GRIFFITHS, MAI
CHHA 9/21/1958 15 PEPPERMINT LANE WILLINGBORO NJ 08046 DISQUALIFICATION 9/29/1999
GRANT, NICOLE CHHA 11/28/1984 18 BUCKNELL DRIVE TOMS RIVER NJ 08757 DISQUALIFICATION 1/31/2017
GRANVILLE, PEDRO JULIO LAB
TECH.
1/30/1962 823 BROADWAY WEST LONG
BRANCH
NJ 07764 DISQUALIFICATION 8/20/2015
GRASSER, JENNIFER AKA
KROWICKI, JENNIFER
RN 7/6/1963 232 CLUB DRIVE WALL NJ 07719 SUSPENSION 10/20/2002
GRAUERHOLZ, JOHN E. MD 12/11/1941 PO BOX 2172 LEESBURG VA 22075 SUSPENSION 9/19/2002
GRAY, KEVIN 129 CHANCELLOR AVENUE NEWARK NJ 07112 DISQUALIFICATION 6/1/1993
GRAY-KEARLY, ASHLEE CHHA 10/24/1987 10 CORAL DRIVE HOWELL NJ 07731 DISQUALIFICATION 1/31/2017
GRAYOVSKI, ELIZABETH CHHA 1/29/1986 206 NORTHFIELD ROAD MILLINGTON NJ 07946 DEBARMENT 7/14/2017
GRAYSON, MURRAY A. RPH 6/9/1941 163 HAMPTON GREEN STATEN ISLAND NY 10312 DISQUALIFICATION 6/1/1993
GRAZIANO, NATALE MD 3/25/1926 470 BROOKSIDE LANE SOMERVILLE NJ 08876 DISQUALIFICATION 12/1/1998
GREEN, JOHN N. MD 10/5/1953 1114072444 61 MAIN STREET WEST ORANGE NJ 07102 SUSPENSION 2/22/2012 6/21/2012
GREEN, JOHN N. MD 10/5/1953 1114072444 3 PADDOCK COURT BASKING RIDGE NJ 07920 DEBARMENT 9/25/2014
GREEN, JOYCE D. CHHA 8/25/1960 PO BOX 145 WOODBINE NJ 08270 SUSPENSION 8/20/2003
GREEN, ROBERT MD 3/30/1921 22 OLD SHORT HILLS RD. LIVINGSTON NJ 07039 DISQUALIFICATION 9/2/1992 DECEASED
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
52
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GREENBERG, ANTHONY MD 3/17/1960 1487641239 576 STATE ROUTE 94 COLUMBIA NJ 08732 DISQUALIFICATION 10/29/2016
GREENBERG, EDMUND RPH 11/15/1939 270 HIGHLAND RD. S. ORANGE NJ 07079 DISQUALIFICATION 2/7/2000
GREENE, LIZA RN 2/5/1974 57 N. RIVER DRIVE PENNSVILLE NJ 08070 SUSPENSION 9/19/2003
GREENFARB, IRVING DO 9/24/1929 160 LITTLETON RD. MORRIS PLAINS NJ 07950 DISQUALIFICATION 12/19/1988 DECEASED
GREENFIELD, RONALD W. 6/11/1955 227 CLUB DRIVE WALL NJ 07719 SUSPENSION 7/19/2001
GREENLEAF, JANICE LPN 3/25/1954 110 EAST JUNIPER AVENUE NORTH WILDWOOD NJ 08260 SUSPENSION 6/20/2005
GREENSPAN, BERNARD DO 7/11/1937 1245231406 484 LAFAYETTE STREET HAWTHORNE NJ 07506 DISQUALIFICATION 8/4/2017 PERMANENT
GREENSPAN, BERNARD DO 7/11/1937 1245231406 150 OVERLOOK AVENUE, 10C HACKENSACK NJ 07601 DISQUALIFICATION 9/29/2017 PERMANENT
GRETZULA, CHAD DMD 8/23/1972 1558422311 616 EAST LANCASTER AVENUE BERWYN PA 19312 DISQUALIFICATION 11/20/2015
GRIETZER, JOY RN 1/4/1964 406 EAST FRANKLIN STREET WEST BERLIN NJ 08091 DEBARMENT 7/22/2017
GRIFFIN, CHARLES RPH 9/15/1985 1669757530 HAZELTON USP, PO BOX 2000 BRUCETON HILL WV 26525 DISQUALIFICATION 11/20/2015
GRIFFIN, REMY CHHA 4/14/1984 490 PARK AVENUE, APT. 3-B PATERSON NJ 07504 DISQUALIFICATION 5/2/2017
GRIMES, BRIDGET 1/31/1957 293 LINCOLN STREET PHILLIPSBURG NJ 08865 DEBARMENT 10/29/2012
GRINSHPUN, LEV CHHA 11/26/1956 501-F MORRIS AVENUE ELIZABETH NJ 07208 DEBARMENT 7/22/2017
GRISSON, SANDRA 2/20/1966 30 SOUTH CHURCH STREET,
APT. 5
WAYNESBORO PA 17268 DISQUALIFICATION 12/29/2015
GROSS, KENNETH M. DC 1/28/1971 1740488709 333 PROVINCIAL DRIVE MORGANVILLE NJ 7751 DISQUALIFICATION 6/20/2018
GROSSETT II, KENNETH W. RPH 6/22/1945 SOUTH DUPONT RD. CARNEYS POINT NJ 08069 SUSPENSION 3/20/2008
GRULLON, KADIA CHHA 1/5/1990 204 ACKERMAN AVENUE CLIFTON NJ 07011 DISQUALIFICATION 4/19/2018
GUENSCH, LISA M. RN 11/2/1966 85 MORNING GLORY RD. WARREN NJ 07059 DISQUALIFICATION 5/20/2009
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
53
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
GUERRERO, RAUL 10/25/1968 110 JEROME AVENUE S. BOUND BROOK NJ 08880 SUSPENSION 1/20/2004
GUERRERO, THAMARA CHHA 4/11/1972 327 OUTWATER LANE #2 GARFIELD NJ 07026 DISQUALIFICATION 4/6/2018
GUERRIERO, LU ANN M. DC 7/14/1956 21 KILMER DR, STE. 2A MORGANVILLE NJ 07751 SUSPENSION 9/24/1997
GUICE SR., JASON C. 1/30/1944 725 ELIZABETH AVENUE NEWARK NJ 07112 SUSPENSION 9/15/2004
GUICE, AZIE 7/9/1944 725 ELIZABETH AVENUE NEWARK NJ 07112 DEBARMENT 9/5/2005
GUILBERT, RICARDO LPN 4/30/1948 SOUTHERN STATE CORREC
FAC
DELMONT NJ 08314 DISQUALIFICATION 11/21/1995
GUILIANO, GINA RN 12/16/1977 1 KINDERKAMACK RD. WOODCLIFF LAKE NJ 07677 SUSPENSION 12/18/2003
GULLA, FRANK T. MD 2/13/1939 113 RTE. 46 W. WILLOW SQ. WAYNE NJ 07470 DISQUALIFICATION 12/7/1999
GUPTA, NAVEEN RPH 4/11/1943 1700 OAK TREE RD. EDISON NJ 08820 DEBARMENT 3/4/1999
GUPTA, RASHMI J. COUNSEL
OR
6/22/1972 203 HASSE AVENUE PARAMUS NJ 07652 DEBARMENT 7/30/2012
GUPTA, RASHMI J. COUNSEL
OR
6/22/1972 10913 CORY LAKE DRIVE TAMPA FL 33647 DEBARMENT 7/3/2013
GURBAN, ELHAN 10/15/1962 14 FAHRNER STREET BERGENFIELD NJ 07621 DISQUALIFICATION 8/16/2016
GURBAN, ELHAN 10/15/1962 SOUTHERN STATE CF, 4295
RT. 47
DELMONT NJ 08314 DEBARMENT 12/16/2015
GUREVICH, NATALIA MD 11/24/1946 31-23 CRESCENT ST. APT 2C ASTORIA NY 11106 SUSPENSION 9/20/2005
GUSSMAN, MICHAEL DPM 6/7/1959 141 GREENBROOK DRIVE MARLTON NJ 08053 SUSPENSION 6/20/2001
GUYTON, KATHLEEN 2/20/1943 228 SANFORD STREET EAST ORANGE NJ 07018 DISQUALIFICATION 8/20/2002
HABIB, IMAD 7/19/1962 1529 39TH STREET, 1ST FL NORTH BERGEN NJ 07047 DISQUALIFICATION 9/30/2011
HAIDER, MOHAMMED M. 1/15/1966 195 BROADWAY PATERSON NJ 07505 SUSPENSION 12/7/1999
HAINES, KEITH E. MD 5/1/1911 1210 BRACE RD. CHERRY HILL NJ 08034 DISQUALIFICATION 10/15/1991 DECEASED
HAINES, RAMONA L. RN 1/15/1959 103 MEADOWVIEW CIRCLE MARLTON NJ 08053 SUSPENSION 8/19/2004
HAINES, ROBBIE A. RN 4/20/1975 WHITE POND COURT ABSECON NJ 08205 SUSPENSION 10/18/2007
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
54
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
HAITMANEK, OTTILLIE M. LPN 9/5/1968 4162 BAYBERRY COURT MONMOUTH
JUNCTION
NJ 08852 DISQUALIFICATION 3/28/2017
HALAS, JOHN 6/23/1945 144 WHITEHALL DRIVE VOORHEES NJ 08043 SUSPENSION 5/20/2002
HALL, AFRIKA AKA
JACKSON, AFRIKA
8/1/1970 BRIARWOOD DRIVE TOBYHANNA PA 18466 DISQUALIFICATION 10/2/2007 6/28/2018
HALL, ANNA M. RN 10/11/1937 44 LAKE TRAIL EAST WAYNE NJ 07470 SUSPENSION 10/18/2001
HALL, KIM 11/18/1965 5 UNAMI LANE SCOTCH PLAINS NJ 07076 DISQUALIFICATION 1/23/2009
HAMAD, ALHIBER K. 4/14/1954 100 RESERVOIR AVENUE JERSEY CITY NJ 07307 DISQUALIFICATION 12/1/1998
HAMBERG, IVAN OD 2/11/1934 49 W. CHELTEN AVENUE PHILADEPHIA PA 19144 DISQUALIFICATION 8/27/2001
HAMDAN, KRISTINA 5/10/1978 7 OAK HILL DRIVE WAYNE NJ 07470 DISQUALIFICATION 11/16/2017
HAMM, CARRIE RN 3/16/1975 1134 N. STILES STREET LINDEN NJ 07036 SUSPENSION 9/19/2003 2/23/2013
HAMM, CARRIE RN 3/16/1975 1134 N. STILES STREET LINDEN NJ 07036 DEBARMENT 2/23/2010 2/23/2013
HAMPTON, GLYNDA 12/11/1960 571 MONTGOMERY STREET JERSEY CITY NJ 07302 DISQUALIFICATION 3/29/2002
HAN, DANIEL 5/20/1988 481 WALKER STREET, APT. 1D FAIRVIEW NJ 07022 DISQUALIFICATION 11/29/2016
HANDERHAN, LEROY J. RN 9/19/1958 909 ABINGTON RD. CHERRY HILL NJ 08034 DISQUALIFICATION 5/20/2007
HANDS, EVELYN CHHA 3/20/1956 789 WHEATLAND COURT CAMDEN NJ 08104 DISQUALIFICATION 1/27/2006
HANNA, ALEXANDRA LPN 12/20/1977 51 NORTHRUP DRIVE BRICK NJ 08724 DISQUALIFICATION 5/2/2018
HANNA, ASHRAF PHARM
TECH
3/11/1985 50 WILLETT AVENUE SOUTH RIVER NJ 08882 DISQUALIFICATION 11/21/2016
HANSCOM, CRYSTAL RPH 1/9/1980 1407 BROMLEY ESTATES PINE HILL NJ 08021 DISQUALIFICATION 8/8/2011 9/6/2016
HARPER, JENNIFER R. RN 12/15/1971 131 HEMLOCK COURT WOODBURY NJ 08096 SUSPENSION 6/19/2003
HARRELL, PAMELA L. RN 4/8/1958 1150 REDROCK CANYON RD KATY TX 77450 SUSPENSION 8/20/2002
HARRIGAN, DAVID C. DC 6/14/1952 1932155736 161 W. WHITE HORSE PIKE ABSECON NJ 08201 DISQUALIFICATION 12/29/1995
HARRIS, JOHNNIE 8/20/1983 2 LAKE BLVD EWING NJ 08638 DISQUALIFICATION 4/22/2006
HARRIS, PAUL MD 3/13/1965 GB-46 PO BOX 26010 BEAUMONT TX 77720 SUSPENSION 11/20/2006
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
55
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
HARRIS-POOLE, IRENE PTA 7/26/1955 708G LUCAS LANE VOORHEES NJ 08043 DEBARMENT 8/20/2003
HARVILIK, DOROTHEA RN 1/23/1953 20 EAST ALLENDALE ROAD SADDLE RIVER NJ 07458 DISQUALIFICATION 6/28/2017 PERMANENT
HASHIM'S MEDICAL LIVERY PO BOX 930 NEW YORK NY 10013 DISQUALIFICATION 3/26/1994
HASSAN, SALAH A. 9/1/1976 105 TONNELLE AVENUE JERSEY CITY NJ 07305 DISQUALIFICATION 5/31/2001
HASSETT, IRENE PHD 12/13/1934 1801894803 950 MORGAN HIGHWAY 226 SOUTH ABINGTON
TWP.
PA 18411 DISQUALIFICATION 11/20/2015
HEALTH PHARMACY, INC. 3 POND ROAD PARSIPPANY NJ 07054 DISQUALIFICATION
HEGGS, PAMELA B. 10/22/1963 PO BOX 4004 CLINTON NJ 08809 DISQUALIFICATION 10/18/2007
HELLER, ELLIOT MD 12/24/1957 1770688723 1150 AMBOY AVENUE EDISON NJ 08837 DISQUALIFICATION 4/29/2003 6/25/2014
HENRY, SARA RN 4/22/1975 54 CARVER AVENUE LINDENWOLD NJ 08021 DISQUALIFICATION 3/7/2008
HERMAN, LAWRENCE S. DC 6/25/1966 1881664761 8908 DANVILLE TERRACE FREDERICK MD 21701 DISQUALIFICATION 12/29/2015
HERMAN, THERESA RN 9/30/1948 676 HARBOR RD. BRICK NJ 08724 SUSPENSION 5/20/2004
HERNANDEZ, JENNIFER
OFELIA
CHHA 1/1/1980 1410 OAK TREE DRIVE (H) NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 6/25/2013
HERNANDEZ, NORA LEE LPN 9/28/1980 4820 OLD HARRISBURG RD. GETTYBURG PA 17325 DISQUALIFICATION 11/20/2015
HERNANDO, GILDA 5/19/1956 669A CHAMBERS STREET TRENTON NJ 08611 DISQUALIFICATION 11/8/2002
HERSCHMAN, ZVI J. MD 1/20/1960 1033217492 346 WILSON STREET WEST HEMPSTEAD NY 11552 DISQUALIFICATION 4/20/2013
HERSCHMAN, ZVI J. MD 1/20/1960 1033217492 1 OLD SHORT HILLS RD. LIVINGSTON NJ 07039 DEBARMENT 10/28/2013
HERSHAN, DAVID MD 11/13/1956 1740280957 3 OWATONNA STREET HAWORTH NJ 07641 DISQUALIFICATION 5/18/2017
HESSEIN, AMGAD A. MD 10/2/1956 1578637260 483 SOUTH ORANGE AVENUE SOUTH ORANGE NJ 07079 SUSPENSION 1/26/2012 5/25/2016
HESSEIN, AMGAD A. MD 10/2/1956 1578637260 483 SOUTH ORANGE AVENUE SOUTH ORANGE NJ 07079 DEBARMENT 5/25/2016
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
56
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
HESSEIN, AMGAD A. MD 10/2/1956 1578637260 BAYSIDE STATE PRISON, PO
BOX F-1
LEESBURG NJ 08327 DISQUALIFICATION 5/1/2017
HEYMACH, GEORGE MD 4/14/1978 1568588317 801 W. 57TH TERRACE KANSAS CITY MO 64113 DISQUALIFICATION 8/27/2001
HEYMAN, JACK DO 12/9/1917 124 E MT. PLEASANT AVENUE LIVINGSTON NJ 07039 DISQUALIFICATION 1/7/1983 DECEASED
HHCH HEALTH CARE 1639294812 ALDERSON FEDERAL PRISON
CAMP, CLAY GRAY ROAD, BOX
A
ALDERSON WV 24910 DISQUALIFICATION 5/24/2017
HICKS, MYASIA CHHA 3/27/1995 38-40 JOHNSON AVENUE NEWARK NJ 07108 DISQUALIFICATION 11/8/2017
HIGGINS, GARY W. RN 4/13/1971 548 WAYSIDE RD. NEPTUNE NJ 07753 SUSPENSION 10/20/2002
HIGGINS, MARTIN 3/12/1943 706 BLOOMFIELD AVENUE NUTLEY NJ 07110 SUSPENSION 7/20/2005
HIGGINS, RANDALL T. RPH 6/3/1986 17 WAVERLY PLACE MATAWAN NJ 07747 DISQUALIFICATION 3/3/2017
HILLEY, KATHLEEN M. 1/6/1973 219 CENTER STREET TUCKERTON NJ 08087 DISQUALIFICATION 10/15/2010
HILTON JR., JAMES R. DO 6/15/1961 28 BROCKTON COURT BEACON FALLS CT 06403 DEBARMENT 4/3/2002
HIMMELWRIGHT, VICTOR 3/24/1919 44 LONDONDERRY WAY SUMMIT NJ 07901 DISQUALIFICATION 6/1/1993
HIRES, STEPHANIE RN 11/18/1972 725 FORD AVENUE LANGHORNE PA 19047 DISQUALIFICATION 2/20/2018
HIRSH, HOWARD RPH 6/6/1952 1811204605 163 EINSTEIN WAY EAST WINDSOR NJ 08512 DISQUALIFICATION 10/25/2016
HO, SHING MD 7/26/1953 6 JAMOR COURT NESCONSET NY 11767 SUSPENSION 10/19/2000
HOCHBERG, JOHN MD 4/10/1952 1134280480 288 PLEASANT VALLEY ROAD MORGANVILLE NJ 07751 DISQUALIFICATION 9/14/2016
HOCHBERG, JOHN MD 4/10/1952 1134280480 288 PLEASANT VALLEY ROAD MORGANVILLE NJ 07751 DISQUALIFICATION 4/17/2017
HODGKISS, KATHLEEN PSYCH 7/13/1977 1013179233 151 KNOLLCROFT ROAD LYONS NJ 07939 DEBARMENT 7/22/2017
HOFFMAN, MARTIN L. MD 8/22/1948 7 CAREFREE LANE SUFFERN NY 10901 DEBARMENT 3/29/2002
HOFFSPIEGEL, PAUL 9/23/1940 56 SULLLIVAN DRIVE WEST ORANGE NJ 07052 SUSPENSION 8/6/1998
HOFSTETTER, DAVID 2/25/1930 114 COUNTY RD. 513 PITTSTOWN NJ 08867 SUSPENSION 6/14/2000
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
57
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
HOLCA, LIVIU MD 1/25/1958 1053348417 1137 BEACON AVENUE MANAHAWKIN NJ 08050 SUSPENSION 11/25/2014
HOLLOWAY, JAZMINE CHHA 2/12/1995 95 CUMMINGS AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 1/23/2018
HOLMES, THERESA CHHA 2/20/1986 1290 N. 27TH STREET CAMDEN NJ 08105 DISQUALIFICATION 2/12/2018 8/20/2018
HOMAN, WALTER W. CHHA 11/24/1959 FORECASTLE AVENUE BEACHWOOD NJ 08722 SUSPENSION 8/21/2008
HOME CARE SOLUTIONS 216 NORTH AVENUE E, STE. 2 CRANFORD NJ 07016 SUSPENSION 1/24/2014
HONG, JOSEPH S. MD 1/1/1964 1346258001 34 FOREST DRIVE WATCHUNG NJ 07069 DISQUALIFICATION 9/29/2016
HOPPE, GERALD 3/15/1940 BOX 483A, RD 1 MONROEVILLE NJ 08343 DISQUALIFICATION 6/1/1993
HORN, MURRAY 7/3/1919 287 GARFIELD AVENUE HAWORTH NJ 07641 DISQUALIFICATION 8/9/1984
HORVATH, CHARLYN RN 7/12/1967 3072 BORDENTOWN AVENUE PARLIN NJ 08859 DISQUALIFICATION 3/27/2018
HORWITZ, KENNETH R. RPH 4/19/1962 8 MOHAWK PLACE RANDOLPH NJ 07869 DEBARMENT 10/31/2003 7/20/2011
HOUSTON, PLATINUM CHHA 1/19/1992 15 COURTLAND LANE WILLINGBORO NJ 08046 DISQUALIFICATION 9/19/2017
HOUTAN, FARAH PTA 7/23/1957 269 STEELMANVILLE RD. EGG HARBOR NJ 08234 SUSPENSION 10/27/2009
HOUTAN, FARAH PTA 7/23/1957 269 STEELMANVILLE RD. EGG HARBOR NJ 08234 DEBARMENT 5/1/2012
HOWARD, REGINA R. 9/6/1989 104 E. 8TH STREET LAKEWOOD NJ 08701 DISQUALIFICATION 10/30/2013
HOWARD, ROBIN A. RN 2/14/1962 196 KING AVENUE TRENTON NJ 08638 DISQUALIFICATION 7/19/2001
HOWELL, BRIAN LPN 7/11/1975 106 PARKER AVENUE #2 FORKED RIVER NJ 08731 DISQUALIFICATION 7/27/2017
HOWELL, CHRISTOPHER CHHA 5/24/1991 978 JOLSON COURT MANCHESTER
TOWNSHIP
NJ 08759 DEBARMENT 10/26/2017
HOWELL, CLIFTON MD 10/15/1956 1942247622 15 COLONY DRIVE WEST WEST ORANGE NJ 07052 DISQUALIFICATION 8/19/2011
HOWELL, CLIFTON MD 10/15/1956 1942247622 15 COLONY DRIVE WEST WEST ORANGE NJ 07052 DEBARMENT 10/18/2012
HRABARCHUK, EUGENE PSYCH 8/29/1920 925 CLIFTON AVENUE CLIFTON NJ 07013 DISQUALIFICATION 12/1/1998
HSIA, VINCENT RPH 10/5/1959 1710209291 SCHUYLKILL FCI MINERSVILLE PA 17954 DISQUALIFICATION 5/1/2014
HU, HSUN TUAN 2/17/1938 154 HOMESTEAD PLACE BOGOTA NJ 07603 DISQUALIFICATION 5/10/1999
HUBBARD, PETER RN 3/6/1960 1051 WASHINGTON STREET EASTON PA 18042 DISQUALIFICATION 10/25/2016
HUDSON, FITZGERALD MD 5/25/1960 1639367725 PO BOX 1000 MILAN MI 48160 DEBARMENT 6/12/2014
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
58
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
HUERTA JR., FRANK 8/27/1973 25 CHAPEL STREET BROOKLYN NY 11201 SUSPENSION 1/10/1997
HUNDA, RAFAEL MD 9/3/1920 472 RIVER STREET PATERSON NJ 07524 DISQUALIFICATION 9/21/2001
HUNTER, CHRISTOPHER LPN 4/23/1961 430 BARTINE STREET SOMERVILLE NJ 08876 SUSPENSION 6/20/2002
HUNTER, FRANK L. 7/5/1964 6 HARTZ DRIVE BRIDGETON NJ 08302 SUSPENSION 2/20/2005
HUNTER-CORREA, LOUISA DDS 6/17/1965 372 FOREST AVENUE PARAMUS NJ 07652 SUSPENSION 10/22/2010
HUSSAIN, IFTIKHAR 6/12/1966 9 VAN COURTLAND AVENUE STATEN ISLAND NY 10301 DISQUALIFICATION 1/29/2003
HUSSAIN, ZAHID MD 12/3/1974 1992733232 301 ROUTE 9 NORTH FREEHOLD NJ 07728 SUSPENSION 9/30/2011 7/22/2016
HUSTON JR., JOHN A. CHHA 9/18/1956 8 PRODUCTION WAY AVENEL NJ 07001 SUSPENSION 8/29/1997
HYMAN, DEBORAH 7/23/1954 6 HASTINGS LANE FLEMINGTON NJ 08822 SUSPENSION 8/20/2006
HYMAN, RONALD M. RPH 2/1/1961 3845 DEMPSEY HUNTINGTON
VALLEY
PA 19006 SUSPENSION 1/19/2005
I & I INVALID COACH 85 CENTRAL AVENUE CLIFTON NJ 07015 SUSPENSION 2/19/2004
IBRAHIM, ELHADI 4/3/1964 125 HALF MILE RD, BOX 190 MIDDLETOWN NJ 07748 DEBARMENT 1/29/2001
IBRAHIM, GASIM 10/25/1963 340 FAIRMOUNT JERSEY CITY NJ 07306 DISQUALIFICATION 12/11/1996
IBRAHIM, MOHAMMAD MD 8/14/1966 1265494645 871 MCBRIDE AVENUE WOODLAND PARK NJ 07424 DEBARMENT 1/22/2016
IGBERASE, OLUWAFEMI
AKA CHARLES IGBERASE
RN 4/17/1962 14909 DOWNEY COURT,
SUITE 200
BOWIE MD 20721 DISQUALIFICATION 5/20/2018
IGBINADUWA, NEWTON RPH 6/20/1955 116-35 139TH STREET JAMAICA NY 11436 SUSPENSION 5/19/2005
IGHAMA-AMEGOR, IBILOLA MD 3/12/1962 1639251804 59 MAPLE AVENUE VAUXHALL NJ 07088 DISQUALIFICATION 8/16/2017
IGNACCOLO, EMANUELE MD 3/9/1932 688 WYCOFF AVENUE MAHWAH NJ 07430 DISQUALIFICATION 6/1/1993 DECEASED
IKEH, CHIDI ETHELBER 11/3/1962 PO BOX 26030 BEAUMONT TX 77720 DISQUALIFICATION 3/9/2008
ILEM, PRISCILLA G. MD 6/14/1927 1699860684 782 ALPS RD. WAYNE NJ 07470 DISQUALIFICATION 10/27/2013
ILLINGWORTH, DONNA LPN 8/20/1959 1505 CLAIRE RD. FORKED RIVER NJ 08731 SUSPENSION 5/19/2005
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
59
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
INFINITE CARE, INC. 1073549671 6423 RISING SUN AVENUE PHILADELPHIA PA 19111 DISQUALIFICATION 12/29/2015
INGALLS, ANDREA CHHA 10/7/1989 36 NORWOOD STREET, 3RD
FLOOR
NEWARK NJ 07106 DISQUALIFICATION 4/19/2018
INNES JR., GEORGE
MICHAEL
MD 1/16/1961 1736 EAST GENESEE ST. FAYETTEVILLE NY 13066 SUSPENSION 7/20/2005
INNOCENZI, ANTHONY DPM 12/14/1969 1255336079 7972 AQUADALE DRIVE YOUNGSTOWN OH 44512 DISQUALIFICATION 12/29/2015
INSABELLA, HARRY DDS 2/5/1958 591 SOMERSET ST. SOMERSET NJ 08873 DISQUALIFICATION 7/1/1997
INTELISANO, RONALD DO 12/28/1961 1235200775 46 BUCKINGHAM DRIVE BERLIN NJ 08009 DISQUALIFICATION 3/3/2017
INTELISANO, RONALD DO 12/28/1961 1235200775 1504 BLACKWOOD
CLEMENTON ROAD
BLACKWOOD NJ 08012 DISQUALIFICATION 12/29/2017
IOSIM, ANATOLY CHHA 9217 FALSTON CIRCLE OLD BRIDGE NJ 08857 DEBARMENT 1/20/2017
IQBAL, MOHAMMED S. MD 11/1/1947 1972564078 735 LINWOOD AVENUE RIDGEWOOD NJ 07450 DEBARMENT 9/12/2008
IRBY, ARCHER DC 10/15/1970 1801927520 115 GRAND AVENUE ENGLEWOOD NJ 07631 DISQUALIFICATION 10/25/2016
IRVING, EDWARD J. 5/14/1969 202 SEYMOUR AVENUE NEWARK NJ 07108 SUSPENSION 4/20/2004
ISAACSON, STEVEN RPH 10/7/1944 1959 BIRCHWOOD PARK DR. CHERRY HILL NJ 08034 DISQUALIFICATION 4/6/1995
ISMAIL, MOHAMMAD RPH 1/25/1957 4 GRAHAM COURT PARSIPPANY NJ 07054 SUSPENSION 12/18/2003
IVASHENKO, ALEXANDER PT 5/10/1957 1134289796 31 GOLDSMITH DRIVE HOLMDEL NJ 07333 SUSPENSION 5/25/1999
IYENGAR, DEVARAJAN MD 7/22/1953 1689620700 27 EAST 29TH STREET BAYONNE NJ 07002 SUSPENSION 8/25/2015 1/10/2017
J & S PHARMACY 214 SECOND STREET ELIZABETH NJ 07207 DISQUALIFICATION 12/1/1998
J & S PHARMACY 214 SECOND STREET ELIZABETH NJ 07207 SUSPENSION 7/11/1997
JACKSON, AMINATU CHHA 6/4/1996 26 JAMES STREET, C12 LAKEWOOD NJ 08701 DISQUALIFICATION 2/8/2017
JACKSON, DESHONETTE CHHA 4/18/1992 419 EAST 27TH STREET, 2ND
FLOOR
PATERSON NJ 07515 DISQUALIFICATION 4/19/2018
JACKSON, GEORGE D. PSYCH 8/20/1928 367 FAIRVIEW AVENUE ORANGE NJ 07050 DISQUALIFICATION 6/30/1997
JACKSON, MAKEBA CHHA 1/24/1976 15 MILL STREET EATONTOWN NJ 07724 DISQUALIFICATION 7/14/2017
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
60
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
JACKSON, ZEKIA CHHA 3/7/1988 232 JUSTIN WAY WILLIAMSTOWN NJ 08094 DISQUALIFICATION 10/19/2017
JACKSON-GILLARD,
CRYSTALYNN
CHHA 6/16/1990 3 BORDEN AVENUE, APT. 8 ASBURY PARK NJ 07712 DISQUALIFICATION 4/24/2018
JACOBS, AMY LPN 9/27/1972 620 MOUNTAIN ROAD BUTLER NJ 07405 DISQUALIFICATION 6/5/2017
JACOBSON, CRAIG DC 11/17/1965 1219 LIBERTY AVENUE HILLSIDE NJ 07205 DISQUALIFICATION 3/24/2000 DECEASED
JACOBSON, DEBRA 2/6/1969 661 RT. 9 BAYVILLE NJ 08721 DISQUALIFICATION 1/25/2011 1/25/2013
JACOBSON, JAY P. DC 5/23/1943 1508084385 25 DEER PATH HOLMDEL NJ 07733 DISQUALIFICATION 4/12/1996
JACQUES, ARNOLD, J. MD 10/15/1949 1124170899 31 BRIDGEWATER COURT JACKSON NJ 08527 DISQUALIFICATION 7/30/2011
JACQUEZ, MADELIN CHHA 11/4/1993 2141 SOUTH CLINTON
AVENUE
HAMILTON NJ 08610 DISQUALIFICATION 2/12/2018
JAFARI, MARYAM MD 9/16/1970 1831276880 80 LINDEN STREET, APT. M MILLBURN NJ 07041 DISQUALIFICATION 9/20/2014
JAFARI, MARYAM MD 9/16/1970 1831276880 176 BLOOMFIELD AVENUE NEWARK NJ 07104 SUSPENSION 2/22/2012
JAFFERY, SYED MD 7/8/1961 1235153685 109 TROTTER ROAD EGG HARBOR NJ 08234 DEBARMENT 2/15/2016
JAGTIANI, RAJA MD 5/31/1961 1659320281 11 ONTARIO STREET DUMONT NJ 07628 SUSPENSION 6/6/2016 11/29/2016
JAGTIANI, RAJA MD 5/31/1961 1659320281 11 ONTARIO STREET DUMONT NJ 07628 DEBARMENT 9/28/2015
JAKUBCZAK, ARTHUR F. DC 6/3/1952 1053493718 465 RATHBURN PLACE PERTH AMBOY NJ 08861 SUSPENSION 1/18/2001 10/26/2001
JAMES, EDWARD DO 7/27/1926 1598789703 505 GROVE STREET, APT. 21 SEWICKLEY PA 15143 DISQUALIFICATION 11/20/2015
JAMES, GLORIA M. RN 10/3/1942 18 LINDEN COURT JERSEY CITY NJ 07305 SUSPENSION 7/20/2005
JAMES, SULENNY CHHA 9/24/1979 293-295 BROAD STREET, 2ND
FL
NEWARK NJ 07104 DISQUALIFICATION 2/27/2017
JAMISON, ROBERT W. DO 4/4/1945 79 PARTRIDGE LANE CHERRY HILL NJ 08003 DEBARMENT 9/11/2000
JANOF, ROY 502 WASHINGTON STREET HOBOKEN NJ 07030 DISQUALIFICATION 1/9/1983
JANVIER-PIERRE, MARY 10/16/1968 6400 BRIDGEPORT LANE LAKE WORTH FL 33463 DEBARMENT 5/20/2012
JARMON, ROBERT G. MD 11/17/1943 8 BRIGHTON AVENUE SPRING LAKE NJ 07762 DEBARMENT 5/9/2002
JASCALEVICH, MARIO E. MD 8/27/1927 10 PRISCILLA LANE ENGLEWOOD CLIFF NJ 07632 DISQUALIFICATION 6/1/1993 DECEASED
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
61
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
JASINSKI, DARIUS DPM 3/17/1975 1013995182 1225 MCBRIDE AVENUE WOODLAND PARK NJ 07424 DEBARMENT 12/29/2016
JASPER, SARAH CHHA 1/6/1985 187 SIERRA COURT WOODBRIDGE NJ 07095 DISQUALIFICATION 1/31/2017
JASPER, THEODORE MD 1/1/1958 1528171972 1010 CLIFTON AVENUE CLIFTON NJ 07013 DEBARMENT 8/12/2015
JASZCZULT, JOAN E. DO 6/29/1961 50 NEWARK AVENUE, APT 309 BELLEVILLE NJ 07109 DEBARMENT 2/3/2006
JAVID, MOHAMMAD A. 3/21/1953 E. JERSEY STATE PRISON RAHWAY NJ 07065 SUSPENSION 8/20/2000
JAVID, MOHAMMED A. 3/21/1953 63 FEDERAL STREET METUCHEN NJ 08840 DISQUALIFICATION 4/11/1996
JAYARAM, AJIT MD 12/20/1947 1295773869 215 SOUTH BURLINGTON RD. BRIDGETON NJ 08302 DISQUALIFICATION 8/20/2013
JAYARAM, AJIT MD 12/20/1947 1295773869 215 SOUTH BURLINGTON RD. BRIDGETON NJ 08302 DISQUALIFICATION 4/4/2014
JEAN-BAPTISTE,
DEMESVAR A.
MD 1/3/1973 1831227719 775 MOUNTAIN BLVD, STE. 1 WATCHUNG NJ 07069 SUSPENSION 9/19/2011 DECEASED
JECK, CHARLES N. DO 6/3/1959 1 CHICKORY PLACE NEWTOWN PA 18940 SUSPENSION 7/5/2002
JEDJU, LINDA RN 3/11/1954 33 NINTH STREET, PO BOX
644
FLAGSTOWN NJ 08821 DISQUALIFICATION 11/27/2016
JEFFERSON, MICHAEL K. DMD 8/12/1954 1811956238 408 PADDOCK COURT SEWELL NJ 08080 DISQUALIFICATION 8/16/2016 5/12/2017
JEFFRIES, MARC 9/5/1964 2 MILLER LANE WHITEHOUSE STAT NJ 08889 DISQUALIFICATION 3/13/2014
JELKS, SAMARRA CHHA 3/9/1982 3309 RIDGEWAY ROAD MANCHESTER NJ 08759 DISQUALIFICATION 3/8/2017
JEMINI, DAVID 2/1/1952 PO BOX 280, HWY. 698 FAIRTON NJ 08320 SUSPENSION 7/18/2002
JEMINI, JACK 7/15/1950 PO BOX 600 ELGIN FL 32542 SUSPENSION 7/18/2002
JIMENEZ, JOSE COUNSEL
OR
6/27/1955 EXTENSION VILLA RITA SAN SEBASTIAN PR 00685 SUSPENSION 12/8/2003 12/8/2011
JIMS TRANSPORTATION 49 WESTERN PARKWAY IRVINGTON NJ 07111 SUSPENSION 4/11/2006
JOACHIM, LEONARD MD 3/10/1950 1720023005 26 LAKE DRIVE MOUNTAIN LAKES NJ 07046 DISQUALIFICATION 12/5/1997
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
62
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
JOACHIM, LEONARD MD 3/10/1950 1720023005 25 HIDEAWAY LANE SPARTA NJ 07871 DISQUALIFICATION 5/15/2017
JOACHIM, STEPHANIE CHHA 10/7/1990 15 LINDSLEY PLACE, APT. 1R EAST ORANGE NJ 07018 DISQUALIFICATION 1/31/2017
JODELKA, ERIK RPH 8/18/1980 1003103946 391 BEECROFT PLACE OAKHURST NJ 07755 DEBARMENT 8/20/2006 2/23/2011
JOHNSON, ALICIA LPN 6/4/1985 20 SKYTOP GARDENS PARLIN NJ 08859 DISQUALIFICATION 9/12/2016
JOHNSON, BRENDA C. LPN 9/24/1973 232 OAK STREET WILLIAMSTOWN NJ 08094 SUSPENSION 1/19/2003
JOHNSON, DEMETRIA CHHA 9/29/1993 21 ROSA PARK BOULEVARD PATERSON NJ 07524 DISQUALIFICATION 7/31/2017
JOHNSON, DENISE M. RN 11/28/1954 12 SIOUX TRAIL DENVILLE NJ 07834 SUSPENSION 4/20/2005
JOHNSON, DUWANA L. CHHA 3/10/1969 213 MARTIN LUTHER KING DR LAKEWOOD NJ 08701 SUSPENSION 9/14/2005
JOHNSON, JULIE ANN CHHA 11/19/1958 1145 MANTUA PIKE MANTUA NJ 08051 SUSPENSION 6/19/2001
JOHNSON, KIM E. LPN 10/20/1961 6B JANS WAY BYRAM TOWNSHIP NJ 07821 DISQUALIFICATION 11/16/2017
JOHNSON, LARHONDA CHHA 10/15/1984 1704 CENTENNIAL VILLAGE CAMDEN NJ 08105 DISQUALIFICATION 2/8/2017
JOHNSON, MICHAEL LPN/RN 5/9/1986 899 DIANE COURT WOODBRIDGE NJ 07095 DISQUALIFICATION 3/28/2017
JOHNSON, ROBERT D. 6/5/1945 1608 4TH AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 1/6/2006
JOHNSTON, KELLIE RN 12/26/1970 1697 SYLVAN DRIVE BLUE BELL PA 19422 SUSPENSION 10/19/2006
JOHNSTON, MICHAEL
#MC4261
MFT 10/4/1960 1780999847 SCI CAMP HILL, PO BOX 200 CAMP HILL PA 17001 DISQUALIFICATION 9/29/2017
JONES, ANIECE LPN 8/20/1984 625 DREXEL AVENUE ATLANTIC CITY NJ 08401 DEBARMENT 6/4/2018
JONES, CYNTHIA R. RN 4/1/1955 1089 HAWSER AVENUE MANAHAWKIN NJ 08050 SUSPENSION 8/20/2002
JONES, DAVID W. LPN 6/27/1952 97 LINCOLN PARK NEWARK NJ 07102 SUSPENSION 3/20/2003
JONES, IMAJE CHHA 4/13/1993 287 ABLETT VILLAGE CAMDEN NJ 08105 DISQUALIFICATION 2/8/2017
JONES, JASMINE CHHA 2/21/1991 304 ERIAL ROAD SICKLERVILLE NJ 08081 DISQUALIFICATION 2/8/2017
JONES, KEVIN PHARM
TECH
8/3/1992 734 STERLING STREET PLAINFIELD NJ 07062 DISQUALIFICATION 7/22/2017
JONES, MICHELLE N. CHHA 11/26/1983 446 PROSPECT STREET-B16 LAKEWOOD NJ 08701 SUSPENSION 9/30/2005
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
63
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
JONES, ROSALIN CHHA 11/30/1970 159 PFEIFFER STREET CAMDEN NJ 08105 DISQUALIFICATION 2/20/2017
JONES-HATTOH, CHATIQUA CHHA 7/8/1984 3 ROANOKE AVENUE, APT. 2C NEWARK NJ 07108 DISQUALIFICATION 1/23/2018
JONES-PRICE, ANTIONETTE 10/17/1965 PO BOX 1006 WENDELL NC 27591 DISQUALIFICATION 6/1/2000
JONES-PRICE, ANTOINETTE 10/17/1965 120 S. 20TH STREET IRVINGTON NJ 07111 SUSPENSION 3/16/1998
JOO, EUI D. MD 11/15/1939 29 TIP TOP WAY BERKELEY HEIGHTS NJ 07922 DISQUALIFICATION 10/14/1985
JORDON, SANDRA LPN 4/26/1966 15 CANIS COURT SEWELL NJ 08080 DISQUALIFICATION 6/5/2017
JOSE, DELIA V. 9/30/1955 185 S. EUCLID ST., SUITE 111 PASADENA CA 91101 SUSPENSION 4/22/1997
JOSHI, JAYENDRA B. 9/13/1959 95-05 37TH AVENUE, APT. 1-A JACKSON HEIGHTS NY 11373 DISQUALIFICATION 6/4/1997
JOSHI, KAJALBEN LPN 8/25/1992 476 EBONY TREE AVENUE GALLOWAY NJ 08205 DISQUALIFICATION 3/12/2018
JOY, RENEE RN 3/29/1968 34 LUTHER ALLEN LANE BRUSH CREEK TN 38547 DISQUALIFICATION 11/16/2017
JRMICK, INC. 911 MAIN STREET BELMAR NJ 07719 DISQUALIFICATION 1/16/2005
JUISTON, PEGGY A. 10/19/1946 17 MYRTLE AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 6/5/2000
JUNGER, SYLVAIN S. MD 4/29/1956 1497975551 270 PENNINGTON AVENUE PASSAIC NJ 07055 DISQUALIFICATION 4/20/2011
JUPITER, RONALD DDS 9/29/1950 1023125879 119 EYLAND AVENUE SUCCASUNNA NJ 07876 DISQUALIFICATION 5/5/2014
JUPITER, RONALD DDS 9/29/1950 1023125879 119 EYLAND AVENUE SUCCASUNNA NJ 07876 DEBARMENT 4/15/2016
JURGENSON, THEODORE
W.
DPM 6/18/1928 438 BROADWAY LONG BRANCH NJ 07746 DISQUALIFICATION 6/1/1993
JYAMFI, CHARLES RPH 9/24/1953 71 OLD SHORT HILLS ROAD WEST ORANGE NJ 07052 SUSPENSION 3/22/2006
KADISHA, INC. 667 MOUNT PROSPECT
STREET
NEWARK NJ 07104 SUSPENSION 5/14/1998
KAHONU, ANNE N. 12/19/1985 315 MILL ST. S. PLAINFIELD NJ 07080 DEBARMENT 1/19/2013
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
64
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KALFUS, DENIS H. DPM 12/9/1945 1015 EAST GLEN AVENUE WASHINGTON TWP NJ 07606 SUSPENSION 6/19/2003
KALINOWSKI, KAROL RN 5/11/1984 31 COVINGTON LANE VOORHEES NJ 08043 DISQUALIFICATION 3/28/2017
KALLEN, HERBERT 10/26/1919 274 RIVER RD. ST JAMES ISLAND NY 11780 DISQUALIFICATION 6/1/1993
KAMARA, HELEN H. CHHA 3/9/1964 PO BOX 509 PALMYRA NJ 08065 SUSPENSION 10/20/2002
KANG, BYUNG MD 1/1/1940 1164599213 122 LONG HILL ROAD LITTLE FALLS NJ 07424 DISQUALIFICATION 9/23/2016
KANIA, RAMESHCHAN MD 12/14/1952 1235158403 310 CENTRAL AVENUE, SUITE
106
EAST ORANGE NJ 07018 DISQUALIFICATION 1/20/2014
KANIA, RAMESHCHAN MD 12/14/1952 1235158403 310 CENTRAL AVENUE, SUITE
106
EAST ORANGE NJ 07018 SUSPENSION 2/22/2012
KANKAM, MARTIN 13 G READING RD. EDISON NJ 07083 DEBARMENT 7/30/2005
KANZ JR., JOHN T. RPH 12/21/1947 136 HILLCREST AVENUE HILLTOP NJ 07542 DISQUALIFICATION 9/17/1984
KAPLAN, DONALD DPM 12/4/1948 1952433567 701 PALMER AVENUE ALLENHURST NJ 07711 SUSPENSION 3/25/2010
KAPLAN, HARMON B. DDS 7/28/1949 1093991044 1251 PATERSON PLANK RD. SECAUCUS NJ 07094 DISQUALIFICATION 8/26/1988
KARASEK, ROBERT D. DMD 4/11/1963 1689794042 559 PLAINFIELD AVENUE BERKELEY HEIGHTS NJ 07922 DISQUALIFICATION 11/20/2014
KARASEK, ROBERT D. DMD 4/11/1963 1689794042 64 DOCKSIDE DRIVE SOMERS POINT NJ 08244 DISQUALIFICATION 9/19/2016
KARES, FRANCES R. RPH 2/8/1950 615 SUMMIT RD. UNION NJ 07083 DISQUALIFICATION 2/16/1983 2/16/1991
KARFUNKEL, DAVID M. 10/12/1970 100 HOWARD AVENUE PASSAIC NJ 07055 DISQUALIFICATION 4/2/2008 10/25/2013
KARGE, FREDRICK PO BOX 190 AVENEL NJ 07001 SUSPENSION 1/28/2007
KARNER, ANNA EMT 11/2/1982 17 MAPLE AVENUE PINE BROOK NJ 07058 DISQUALIFICATION 7/23/2002
KARSHENBOYM,
ALEXANDER
8/7/1961 90 WEST HILL RD. WOODCLIFF LAKE NJ 07677 DEBARMENT 9/20/2007
KAUFMAN, SHOSHANA
AKA STOCKELBERG,
SHOSHANA
LCSW 11/10/1977 349 JESTER COURT OLD BRIDGE NJ 08857 DISQUALIFICATION 7/15/2009 11/7/2014
KAUL, RICHARD MD 11/5/1964 1902838790 292 ATLANTIC STREET HACKENSACK NJ 07601 DEBARMENT 8/1/2014
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
65
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KAVROS, STEVEN J. DPM 7/22/1954 1316912801 12 HERITAGE COURT CHERRY HILL NJ 08034 DISQUALIFICATION 6/1/1993
KAWAM JABAKJI,
MOHAMED
MD 1/27/1959 1760541312 6 BARKER PLACE WAYNE NJ 07470 DEBARMENT 5/16/2016
KAWAM JABAKJI,
MOHAMED
MD 1/27/1959 1760541312 6 BARKER PLACE WAYNE NJ 07470 DISQUALIFICATION 7/20/2017
KAY, KWAME CHHA 7/1/1985 PO BOX 961186 MIAMI FL 33296 DISQUALIFICATION 2/8/2017
KEE, TERRAYA C. CHHA 7/25/1985 CLINTON STREET CAMDEN NJ 08105 DISQUALIFICATION 11/30/2007
KEELEN, SUSAN RN 6/7/1965 272 OLD YORK RD. FLEMINGTON NJ 08822 SUSPENSION 6/20/2001 1/27/2012
KEENEY, RICHARD DC 6/29/1946 1255461430 112 BALTIMORE STREET HANOVER PA 17331 DISQUALIFICATION 12/29/2015
KELLEY, JANINE RN 4/19/1981 126 S. LECATO AVENUE AUDOBON NJ 08106 DISQUALIFICATION 2/2/2018 PERMANENT
KELLOGG, WILLIAM T. MD 4/29/1946 47 MAPLE STREET, STE. 204 SUMMIT NJ 07901 DISQUALIFICATION 1/9/1996 2/28/2014
KELLUM, BETZAIDA CHHA 10/20/1987 1936 S. 8TH STREET, APT. B13 CAMDEN NJ 08104 DISQUALIFICATION 2/8/2017
KELLUM, EARLENE CHHA 5/25/1978 279 S. BLACKHORSE PIKE MOUNT EPHRAIM NJ 08059 DISQUALIFICATION 3/5/2018
KELLY, MICHELLE 963 PARK AVENUE PLAINFIELD NJ 07060 DEBARMENT 3/24/2002
KELLY-UPPER, DENISE 7/21/1955 2200 ATLANTIS AVENUE MAYS LANDING NJ 08330 DISQUALIFICATION 12/1/1998
KEMENY, GEORGE MD 5/11/1951 39 THIRD STREET ELIZABETH NJ 07206 DISQUALIFICATION 11/22/1977
KEMOKAI, JOSEPHINE LPN 12/27/1955 29 BENNETT AVENUE RANDOLPH NJ 07869 DISQUALIFICATION 11/21/2016
KESHISHIAN, PAUL DO 6/25/1951 1437207610 625 COBH RD. RIVER VALE NJ 07675 DEBARMENT 4/22/1999 3/15/2000
KEYES, DONNA CHHA 6/25/1976 4433 EAST MILLS ROAD MAPLE SHADE NJ 08052 DISQUALIFICATION 2/20/2017
KHAIR, IMADELIN A. 12/30/1959 160 ALABAMA AVENUE PATERSON NJ 07505 SUSPENSION 1/28/2001
KHAIR, IMADELIN A. 12/30/1959 FORT DIX FCI, PO BOX 2000 JOINT BASE MDL NJ 08640 DISQUALIFICATION 5/24/2017
KHAJAVI, ABDOLALI MD 1/1/1931 HIGHWAY 94 & OSBOW LANE FRANKLIN NJ 07416 DEBARMENT 8/20/1999
KHAN, ASIF ALI 8/31/1961 909A BROAD STREET NEWARK NJ 07102 SUSPENSION 6/5/1996
KHAN, AZAM HAYAT 1/18/1962 687 FRELINGHUYSEN AVENUE NEWARK NJ 07114 SUSPENSION 12/16/1998
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
66
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KHAN, AZAM HAYAT 1/18/1962 687 FRELINGHUYSEN AVENUE NEWARK NJ 07114 DISQUALIFICATION 10/21/1999
KHAN, AZAM HAYAT 1/18/1962 107 CHARLESTON AVENUE STATEN ISLAND NY 10309 DISQUALIFICATION 7/7/2008
KHAN, MUNIR 8/15/1953 238 GRAND ST., APT. 1 JERSEY CITY NJ 07302 DEBARMENT 8/20/2009
KHAN, SALEEM M. 9/19/1967 336 2ND ST., APT. 1 JERSEY CITY NJ 07302 SUSPENSION 7/20/2003
KHAN, TAUQIR 8/17/1958 PO BOX 420 FAIRTON NJ 08320 SUSPENSION 8/19/2010
KHANDWALA, NITIN RPH 8/24/1951 225 MILLBURN AVENUE MILLBURN NJ 07041 DISQUALIFICATION 10/21/1999 11/29/2012
KHANNA, YASH K. MD 12/28/1941 1093805012 825 BLOOMFIELD AVE., STE.
L1
VERONA NJ 07044 SUSPENSION 2/22/2012
KHANNA, YASH K. MD 12/28/1941 1093805012 310 CENTRAL AVENUE EAST ORANGE NJ 07018 DISQUALIFICATION 11/30/2014
KHARKOVER, ALEKSANDR PT 2/13/1962 1861594889 FCI FORT DIX, PO BOX 2000 FORT DIX NJ 08640 DISQUALIFICATION 11/20/2013
KHURANA, NORENDRA 8/15/1944 32 ROLLING HILLS LANE HARRISON NY 10528 DISQUALIFICATION 6/1/1993
KIBALLO, MARIAN B. RN 10/29/1949 4 OJIBWA COURT WARETOWN NJ 08758 SUSPENSION 12/18/2003
KILLEN, DAWN LPN 8/13/1961 804 COTSWOLD RD. SOMERDALE NJ 08083 SUSPENSION 9/20/2006
KILLMEYER, LINDA RN 5/12/1955 875 QUAKER CHURCH ROAD PERRYOPOLIS PA 15473 DISQUALIFICATION 12/29/2015
KIM, DOYOUN MD 2/14/1924 545 KEARNY AVENUE KEARNY NJ 07032 SUSPENSION 10/30/1998
KIM, DOYOUN MD 2/14/1924 2302 BAY HEAD DRIVE PARLIN NJ 08859 DISQUALIFICATION 7/13/1999
KIM, JENNIFER J. RPH 10/13/1965 1117 INWOOD TERRACE FORT LEE NJ 07024 DEBARMENT 10/23/2003
KIMBLE, SABRINA 6/4/1965 341 OSBOURNE TERRACE, 2C NEWARK NJ 07106 DISQUALIFICATION 2/23/2009
KIMMEL, STEVEN DO 420 DELAWARE ST. MINNEAPOLIS MN 55455 DEBARMENT 4/1/2002
KINDER, EDWARD P. 3/24/1965 5180 LA TERRA AVENUE PAHRUMP NV 89061 DEBARMENT 7/17/2009 7/17/2014
KING, DEBORAH AKA
BENTON, DEBORAH
LPN 5/10/1958 9 RADFORD PLACE WILLINGBORO NJ 08046 DISQUALIFICATION 10/18/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
67
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KING, JOHN ANDERSON DO 8/15/1958 11310 S. ORANGE BLOSSOM ORLANDO FL 23837 SUSPENSION 3/20/2007
KING, WILLIAM MD 4/7/1945 1457411670 LEWISBURG USP, BOX 1000 LEWISBURG PA 17837 DISQUALIFICATION 8/20/2010
KINGS PHARMACY 716 MARKET STREET GLOUCESTER NJ 08030 DISQUALIFICATION 12/29/2004
KIRWIN, SHANNON RN 5/19/1973 114 NORTHMONT AVENUE MOUNT EPHRAIM NJ 08059 SUSPENSION 1/18/2007
KISSAM, JEFFREY 6/14/1955 1506 RUSTIC DRIVE OCEAN TOWNSHIP NJ 07712 DISQUALIFICATION 11/28/1992
KLAUMENZER, JANE RN 12/7/1967 8 TENNESSEE AVENUE LONG BEACH TWP. NJ 08008 SUSPENSION 4/20/2003
KLAUSNER, MARC RPH 10/5/1951 4515 BERGENLINE AVENUE UNION CITY NJ 07087 SUSPENSION 12/29/1999
KLAUSS, GUNNAR MD 12/8/1970 1962685305 30 PROSPECT AVENUE HACKENSACK NJ 07601 DEBARMENT 8/1/2014 6/22/2017
KLEES, DAVID DO 3/1/1957 1527 LINWOOD AVENUE ERIE PA 16510 DISQUALIFICATION 11/20/2015
KLEINMAN, MARSHA PSYCH 4/20/1951 1043332893 32 NORTH 7TH AVENUE HIGHLAND PARK NJ 08904 DISQUALIFICATION 12/4/2012
KLEINMAN, MARVIN
AUDIOLO
GIST 11/15/1950 1609995307 1 CLARIDGE DRIVE, APT. 508 VERONA NJ 07044 DISQUALIFICATION 2/11/2016
KLEMMONS, IRA DDS 9/6/1948 1841393386 23 DEERPATH LANE COLTS NECK NJ 07722 DISQUALIFICATION 8/7/2017
KLEYMAN, VLADIMIR RPH 4/5/1971 1386957710 3 CATHEDRAL DRIVE LAKEWOOD NJ 08701 DEBARMENT 1/23/2016
KLEYMAN, VLADIMIR RPH 4/5/1971 1386957710 3 CATHEDRAL DRIVE LAKEWOOD NJ 08701 DISQUALIFICATION 5/12/2016
KMET, BOGDAN 5/12/1984 363 EAST ROOSEVELT
BOULEVARD
PHILADELPHIA PA 19120 DISQUALIFICATION 11/20/2015
KMET, NAZARIY 5/9/1978 2284 SANDTRAP RD. JAMISON PA 18929 DISQUALIFICATION 11/20/2015
KMET, ROSTISLAV 2/2/1989 13021 BLAKESLEE DRIVE, APT.
A
PHILADELPHIA PA 19116 DISQUALIFICATION 11/20/2015
KOBYLECKYJ, CHRYSTYNA RN 6/22/1965 35 WOODCOCK MOUNTAIN
ROAD
WASHINGTONVILLE NY 10992 DISQUALIFICATION 9/29/2015
KOCH, MARK DO 9/9/1959 1528102647 336 BARNES RD. MONROEVILLE AL 36460 DISQUALIFICATION 11/20/2015
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
68
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KOGAN, VADIM RN 9/2/1966 56 NORMANDY DRIVE PRINCETON JUNCT NJ 08550 SUSPENSION 12/18/2003
KOLLMER, W. LANCE MD 6/3/1948 101 OLD SHORT HILLS RD. WEST ORANGE NJ 07052 DEBARMENT 7/18/2001 DECEASED
KONTOS, DEMETRIUS D. MD 3/27/1935 463 TENAFLY RD. ENGLEWOOD NJ 07631 SUSPENSION 2/20/2000
KOPLITZ, MARSHALL 1/16/1960 256 NORWOOD AVENUE DEAL NJ 07723 SUSPENSION 12/10/1999
KORNAK, PAUL H. MD 7/11/1951 ELKTON FCI, BOX 10 LISBON OH 44432 DISQUALIFICATION 4/19/2007
KOSLOV, GLEB M. DC 9/30/1958 1366584583 388 RAMAPO VALLEY RD. OAKLAND NJ 07436 DISQUALIFICATION 12/1/1998
KOTHALANKA,
SITARAMAKRISHNA
MD 6/14/1950 1184644080 562 SW ROMORA BAY PORT LUCIE FL 34986 DISQUALIFICATION 10/25/2016
KOTTURI, SHIVA MD 2/15/1950 1013168251 512 KEARNY AVENUE, SUITE B KEARNY NJ 07032 DISQUALIFICATION 6/17/2018 PERMANENT
KOUSOULIDES, LOUISE RN 4/13/1961 34 TOPANEMUS LN, APT. 14 FREEHOLD NJ 07728 DISQUALIFICATION 4/20/2009
KOUZMA, NATALIA CHHA 2/8/1971 122 CHELSEA WAY BRIDGEWATER NJ 08807 DISQUALIFICATION 2/8/2017
KOVAR, GRACE M. RN 2/18/1956 929 CHELSEA DRIVE BRICKTOWN NJ 08724 SUSPENSION 5/19/2005
KOWNACKY, MEGAN RN 7/9/1986 622 WALDEN WAY LUMBERTON NJ 08048 DISQUALIFICATION 8/28/2017
KOZIUPA, HELENE A. LPN 1/19/1953 64 WESLEYAN DRIVE TRENTON NJ 08690 SUSPENSION 10/20/2002
KRAEMER, LINDA MARIE LPN 9/14/1967 436 SAINT ANDREW PLACE MANALAPAN NJ 07726 SUSPENSION 10/19/2006
KRAKAUER, RANDALL MD 4/25/1949 1588811012 900 W MAIN ST FREEHOLD NJ 07728 DISQUALIFICATION 2/25/1985
KRAMER JR., EDWARD DC 7/26/1955 1285762401 106 MOTT ROAD BLAIRSTOWN NJ 07825 DISQUALIFICATION 9/28/2017 PERMANENT
KRAMER, LARRY S. RPH 1/18/1963 650 PALISADES AVENUE ENGLEWOOD CLIFF NJ 07632 DISQUALIFICATION 1/10/2003
KREISMAN, MARCIA 4/5/1956 8800 BLVD EAST, APT. 6J NORTH BERGEN NJ 07047 SUSPENSION 12/20/2004
KRESKI, CHRISTINA RN 5/9/1985 2667 PAXTONVILLE ROAD MIDDLEBURG PA 17842 DISQUALIFICATION 12/29/2015
KRICHEVSKY, RITA MD 4/5/1957 1851561963 4429 DRIFTWOOD DRIVE PHILADELPHIA PA 19129 DISQUALIFICATION 9/20/2017
KRIVOSHIK, MARK MD 2/14/1959 1669409306 16 YEGER DRIVE ALLENTOWN NJ 08501 DISQUALIFICATION 11/20/2015
KROHN, IVAN T. MD 6/2/1943 1467429258 33 NORTHWOOD DRIVE VINELAND NJ 08360 DEBARMENT 5/20/2012
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
69
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KROHN, IVAN T. MD 6/2/1943 1467429258 33 NORTHLAND DRIVE VINELAND NJ 08360 DISQUALIFICATION 4/20/2011
KROMAH, ANGIE RN 1/5/1959 3206 LAWNDALE DRIVE EAST GREENSBORO SC 27408 DISQUALIFICATION 5/2/2017
KRUTOYARSKY, IRINA 2/23/1954 ALDERSON FEDERAL PRISON
CAMP, #65107, CLAY GRAY
ROAD, BOX A
ALDERSON WV 24910 DISQUALIFICATION 12/12/2016
KUBACKI, JOSEPH MD 4/7/1949 1306834213 PO BOX 3949 PENSACOLA FL 32516 DEBARMENT 5/20/2013
KUBLIN, ANNE MD 6/21/1960 182 WHALEPOND RD. EATONTOWN NJ 07724 SUSPENSION 3/19/2004
KUKASH, ABIGAIL 2/16/1967 6648 WEXFORD AVENUE RICHMOND VA 23255 DISQUALIFICATION 12/1/1998
KUKASH, MAJDI 4/6/1970 87-02 PENNSBURY PLACE RICHMOND VA 23255 DISQUALIFICATION 12/1/1998
KUKREJA, NAV R. MD 1/8/1958 1295739662 1331 COVENTRY COURT ISELIN NJ 08830 DEBARMENT 2/15/2016
KULYK, ODARKA CHHA 10/19/1951 6 COLBY COURT LINCOLN PARK NJ 07035 DISQUALIFICATION 2/8/2017
KUMAR, ANIL 7/1/1945 184 OLD BEEKMAN RD. MONMOUTH
JUNCT.
NJ 08852 DISQUALIFICATION 1/14/2005
KUMAR, SAROJ 1/22/1954 184 OLD BEEKMAN RD. MONMOUTH
JUNCT.
NJ 08852 DISQUALIFICATION 1/14/2005
KURAN, BASSEM 10/28/1992 FCI FAIRTON, PO BOX 420 FAIRTON NJ 08320 DISQUALIFICATION 8/7/2017
KURBAN, HAKAN 3/28/1969 41 SIDNEY AVENUE RUTHERFORD NJ 07070 DISQUALIFICATION 6/22/1999
KURIAN, LISSYAMMA RN 9/1/1976 1253 COLLIDGE AVENUE UNION NJ 07083 SUSPENSION 10/20/2002
KURLANDER-ZAKARIA,
TRACI
RN 3/20/1962 20 ROCK ROYAL RD. TRENTON NJ 08620 DISQUALIFICATION 2/26/2010
KURTZ, JOEL P. DMD 10/1/1944 1285874743 9 WESTGATE RD. LIVINGSTON NJ 07039 SUSPENSION 5/19/2005
KUSHMAN, JOSEPH MD 8/21/1972 1205025541 224 COLONIAL AVENUE UNION NJ 07083 DISQUALIFICATION 6/28/2017
KUSHNER, ALAN DC 10/8/1950 1558398396 SCI GRATERFORD, JG1165, PO
BOX 244
GRATERFORD PA 19426 DISQUALIFICATION 11/20/2015
KUYINU, MICHAEL MD 9/28/1947 1235173568 34 VANDERVEER DRIVE BELLE MEAD NJ 08502 DEBARMENT 12/16/2015
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
70
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
KYMER, RHIANNON
(ROOSMA)
RN 4/1/1980 8 SPENCER LANE WARREN NJ 07059 DISQUALIFICATION 3/27/2018
LABORDE, JAMES DC 6/3/1955 1578541504 329 SOUTH HIGHLAND STREET DUBOIS PA 15801 DISQUALIFICATION 11/20/2015
LABOY, MICHELLE LPN 9/17/1974 71 LYCEUM COURT STATEN ISLAND NY 10310 DISQUALIFICATION 5/2/2017 11/2/2017
LABRUNA, VINCENT DDS 12/12/1960 1801192216 227 EAST 19TH STREET NEW YORK NY 10003 DISQUALIFICATION 7/22/2002 1/29/2018
LABRUNA, VINCENT DDS 12/12/1960 1801192216 227 EAST 19TH STREET NEW YORK NY 10003 SUSPENSION 9/19/2002 1/29/2018
LACEY, JOAN R. RN 12/4/1947 479 INNES RD. WOODRIDGE NJ 07075 SUSPENSION 10/19/2000
LACRICCHIO, RICHARD C. 150 ROUTE 150 DENVILLE NJ 07834 DISQUALIFICATION
LAFON, MICHAEL MD 1/28/1958 1609168715 107 E. MANTUA AVENUE WENONAH NJ 08090 DISQUALIFICATION 3/28/2004 2/16/2015
LAGRADA, WILLIAM MD 7/6/1960 1316996762 1300 MAIN STREET, STE. 2D CLIFTON NJ 07011 SUSPENSION 2/15/2012 9/25/2014
LAGRADA, WILLIAM MD 7/6/1960 1316996762 15 FORSYTHIA DRIVE EDISON NJ 08837 DEBARMENT 9/25/2014
LAGUERRE, JEAN EDWARD RPH 9/19/1968 1 62ND STREET, APT. 4C W. NEW YORK NJ 07093 DEBARMENT 8/16/2007
LAGUERRE, JEAN EDWARD RPH 9/19/1968 1 62ND STREET, APT. 4C WEST NEW YORK NJ 07093 DISQUALIFICATION 2/29/2008
LAIDO, JOSEPH CHHA 8/27/1964 722 SIXTH STREET LYNDHURST NJ 07071 DISQUALIFICATION 2/8/2017
LAJEWSKI, WAYNE MD 1/17/1963 1558364166 FCI FORT DIX, PO BOX 2000 JOINT BASE MDL NJ 08640 DISQUALIFICATION 10/20/2015
LALLEMAND JR., ROGER MD 1/7/1973 1770575821 4 TYCOR COURT HOLMDEL NJ 07733 DISQUALIFICATION 12/20/2014
LAM, MICHAEL CHUNG KAY MD 2/19/1966 1184656050 1625 ANDERSON AVENUE FORT LEE NJ 07024 DEBARMENT 3/6/2014
LAM, MICHAEL CHUNG KAY MD 2/19/1966 1184656050 2 8TH STREET ENGLEWOOD CLIFF NJ 07632 DISQUALIFICATION 11/14/2014
LAMBRIOLA, VINCENT P. DDS 5/1/1956 143 LITTLE FALLS CEDAR GROVE NJ 07009 DISQUALIFICATION 2/20/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
71
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
LAMP, REBECCA RN/CNP 2/14/1963 1568511236 139 DERWOOD DR. NEW CUMBERLAND WV 26407 DISQUALIFICATION 11/20/2015
LAMPARELLI, NICHOLAS RPH 11/10/1935 149 SUMMIT AVENUE ISLAND HEIGHTS NJ 08732 DISQUALIFICATION 4/30/2003
LAMPROU JR., EMANUEL MD 9/9/1953 1033104526 509 N. BROAD ST. WOODBURY NJ 08096 DEBARMENT 12/18/2012 12/18/2015
LANCE-LANNIGAN, JUDITH 8/27/1955 12 PROSPECT HILL FLEMINGTON NJ 08822 DISQUALIFICATION 7/23/2010
LANDOU, LISSA S. DC 5/1/1959 17B 16TH AVENUE ELMWOOD PARK NJ 07407 SUSPENSION 4/18/2002
LANE, EDWIN MD 1/13/1943 BEACHWOOD NJ 08722 DISQUALIFICATION DECEASED
LANG, ANTHONY 12/19/1979 151 SOUTH DURAND PLACE IRVINGTON NJ 07111 DISQUALIFICATION 10/19/2009 10/19/2014
LANG, BRIAN E. LPN 3/2/1965 634 SPROUL STREET CHESTER PA 19013 SUSPENSION 3/20/2006
LANG, DEBRA CHHA 9/1/1958 124 VAN BUSKIRK RD. TEANECK NJ 07666 SUSPENSION 10/20/2002
LANGLIEB, MARTIN S. DDS 12/11/1931 94 MIDLAND AVENUE FAIRLAWN NJ 07410 DEBARMENT 8/25/1999
LANNON, JENNIFER RN 4/22/1981 520 COLLINGS AVENUE COLLINGSWOOD NJ 08108 DISQUALIFICATION 6/4/2018
LAPORTE, EDYNE RN/LPN 2/8/1979 1107 FURTH RD. VALLEY STREAM NY 11581 SUSPENSION 9/27/2007
LASHKEVICH, JOHN P. 11/20/1959 9 CHARLES LANE CHERRY HILL NJ 08003 SUSPENSION 5/8/1998
LASTIVKA, MARTA CHHA 1/11/1958 28 WINDING WOOD, APT. 2-B SAYREVILLE NJ 08872 DISQUALIFICATION 2/8/2017
LASTRA, ABRAHAM 2/12/1970 500 HIGHLAND AVENUE NEWARK NJ 07102 DISQUALIFICATION 4/15/1999
LASTRA, ABRAHAM 2/12/1970 1808 BERGENLINE AVENUE UNION CITY NJ 07087 SUSPENSION 12/20/2010
LATAWIEC, ANDREA RN 3/7/1964 1681 RARITAN RD. CLARK NJ 07066 SUSPENSION 5/20/2002
LATCHMAN, BHANWATIE PHARM
TECH
4/9/1977 76 WATSON AVENUE EAST ORANGE NJ 07052 DEBARMENT 5/16/2016
LAURIA, SHANNON CHHA 4/7/1974 86 FORT DE FRANCE AVENUE TOMS RIVER NJ 08757 DISQUALIFICATION 4/7/2017
LAURITANO, LAURA RN 9/4/1971 47 OLD ORCHARD COURT CEDAR GROVE NJ 07009 DISQUALIFICATION 6/28/2017
LAVELLE, BARBARA RN/APN 8/28/1958 550 LINCOLN AVENUE RIDGEFIELD NJ 07657 SUSPENSION 12/18/2003
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
72
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
LAVNEVICH, NAUM CHHA 6/21/1967 11 HIAWATHA BOULEVARD OAKLAND NJ 07436 SUSPENSION 11/4/2014
LAVNEVICH, NAUM CHHA 6/21/1967 11 HIAWATHA BOULEVARD OAKLAND NJ 07436 DISQUALIFICATION 2/11/2016
LAZOW, SOLOMON M. MD 6/17/1902 199 MAIN ST MATAWAN NJ 07747 DISQUALIFICATION 6/1/1993
LEATHERDALE, LAURA CHHA 8/27/1982 4 MEETINGHOUSE RD. WRIGHTSTOWN NJ 08562 SUSPENSION 9/19/2003
LEE JR., SAMUEL RPH 8/19/1940 34 PINAFORE LANE WILLINGBORO NJ 08046 DISQUALIFICATION 7/30/1997
LEE, AUGUSTINE MD 10/11/1942 1255478269 905 STUYVESANT AVENUE TRENTON NJ 08618 SUSPENSION 12/22/2011
LEE, AUGUSTINE MD 10/11/1942 1255478269 PO BOX 329002 BROOKLYN NY 11232 DEBARMENT 10/29/2013
LEE, BRIAN LPN 2/13/1968 1722 COPE STREET CAMDEN NJ 08104 SUSPENSION 10/20/2002 8/9/2013
LEE, CHANG HO MD 12/16/1946 1679795181 535A 7TH STREET PALISADES PARK NJ 07650 DISQUALIFICATION 7/20/2015
LEE, DAVID MD 9/24/1957 1275633562 46 CONSTITUTION DRIVE SOUTHAMPTON NJ 08088 DISQUALIFICATION 12/22/2016 PERMANENT
LEE, LAURA 1/7/1960 7280 LEMINGTON AVENUE PITTSBURGH PA 15206 DISQUALIFICATION 11/20/2015
LEE, STEVE Y. DDS 2/10/1961 1219 MAIN AVENUE CLIFTON NJ 07111 SUSPENSION 7/19/2001
LEE, SYLVIA S. MD 9/22/1952 1275518490 27 SUNSET PLACE EMERSON NJ 07630 DEBARMENT 8/26/2013
LEEDS, GARY MD 6/27/1953 1316005036 77 WEST 15TH STREET, APT. 6-
H
NEW YORK NY 10011 DEBARMENT 11/21/2016
LEEDS, GARY MD 6/27/1953 1316005036 16 ELIZABETH LANE RIVERSIDE CT 06878 DISQUALIFICATION 5/24/2017
LEIBER, CHARLES 12/29/1938 5804 BOARDWALK, APT. 104 VENTOR NJ 08406 SUSPENSION 5/22/2007
LEIBMAN, JOSEPH B. MD 5/30/1960 PO BOX 1005 PORT JERVIS NY 12771 DEBARMENT 6/22/2000
LEKWAUWA, CHUKWUEKE RN 1/1/1967 1643 PARK STREET RAHWAY NJ 07065 DEBARMENT 8/28/2017
LEON, JACK 6/9/1965 2991 E. CHESTNUT AVE., UNIT
H80
VINELAND NJ 08360 DISQUALIFICATION 2/22/2000
LEON, JACK 6/9/1965 1071 E. LANDIS AVENUE VINELAND NJ 08360 SUSPENSION 6/29/1998
LEONARD, BARRY A. MD 3/6/1942 15 DARIEN DRIVE CHERRY HILL NJ 08003 DISQUALIFICATION 2/13/1996
LEONARD, JUDITH RPH 12/10/1958 70 LAUREL DRIVE LITTLE SILVER NJ 07739 SUSPENSION 2/20/2005
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
73
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
LEONARD, TROY COUNSEL
OR
12/26/1983 1851691448 999 COLONIAL ROAD FRANKLIN LAKES NJ 07417 DISQUALIFICATION 11/22/2016 PERMANENT
LEPKO, ERVIN MD 2/11/1928 18 JANE DRIVE ENGLEWOOD NJ 07632 SUSPENSION 5/20/2002
LERNER, ELIZABETH 8/8/1967 GLEN RAY RD., BOX A ALDERSON WV 24910 SUSPENSION 7/20/2008
LERNER, MARVIN H. MD 9/20/1944 1321 WASHINGTON STREET HOBOKEN NJ 07030 DISQUALIFICATION 3/5/2002
LESLIE, GLENN R. DO 11/19/1954 1285712950 10 FRANKLIN TURNPIKE MAHWAH NJ 07430 SUSPENSION 4/3/2014 11/20/2015
LESLIE, GLENN R. DO 11/19/1954 1285712950 245 WOODLAND AVENUE RAMSEY NJ 07446 DEBARMENT 11/20/2015
LESLIE, GLENN R. DO 11/19/1954 1285712950 FMC - LEXINGTON, PO BOX
14500
LEXINGTON KY 40512 DISQUALIFICATION 1/9/2016
LEVELL, CRYSTAL LPN 3/7/1972 143 N. 12TH STREET NEWARK NJ 07107 SUSPENSION 8/20/2001 7/23/2012
LEVIN, HARVEY M. MD 3/19/1935 510 NORTH KINGS HIGHWAY CHERRY HILL NJ 08034 DISQUALIFICATION 6/1/1993
LEVINE, EDWARD J. MD 12/27/1951 7 GREEN HILL RD. COLTS NECK NJ 07722 SUSPENSION 6/22/1999
LEVY, EDWARD E. DDS 5/3/1964 108-34 67TH AVENUE FOREST HILLS NY 11375 DEBARMENT 12/29/2011
LEVY, RICHARD S. DPM 1/8/1953 177 MAIN ST. SUITE 235 FORT LEE NJ 07024 SUSPENSION 12/20/2001
LEWANDOWSKI, KENNETH DO 9/16/1963 1114070398 100 ATLANTIC AVENUE CAMDEN NJ 08101 DEBARMENT 8/28/2014
LEWANDOWSKI, KENNETH DO 9/16/1963 1114070398 24 PEACH BLOSSOM LANE MIDDLETOWN NJ 07748 DISQUALIFICATION 11/20/2015
LEWANDOWSKI, KENNETH DO 9/16/1963 1114070398 24 PEACH BLOSSOM LANE MIDDLETOWN NJ 07748 DEBARMENT 6/30/2016
LEWIN, TASHEIKA CHHA 12/13/1990 139 B 14TH AVENUE ELMWOOD PARK NJ 07407 DISQUALIFICATION 7/14/2017 8/21/2018
LEWIS, ERICA CHHA 1/13/1989 1098 PENNSYLVANIA AVENUE FRANKLINVILLE NJ 08322 DISQUALIFICATION 1/29/2018
LEWIS, TOLIA CHHA 2/6/1990 391 ISABELLA AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 9/19/2017
LEYBA, ROGELIO 3/1/1973 24 WEBSTER STREET NEWARK NJ 07104 DISQUALIFICATION 2/11/2016
LEYSON, JOSE MD 8/17/1945 1528169539 6 RANNEY ROAD LONG VALLEY NJ 07853 DISQUALIFICATION 6/30/2018 PERMANENT
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
74
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
LI, STAN MD 2/10/1954 1386631794 16 SECRETARIO WAY HAMILTON NJ 8690 DISQUALIFICATION 8/20/2015 PERMANENT
LI, STAN MD 2/10/1954 1386631794 16 SECRETARIO WAY HAMILTON NJ 8690 DISQUALIFICATION 11/18/2015 PERMANENT
LIBRIZZI, MICHELLE H. LPN 3/25/1961 5 BELLIS CT. RINGOES NJ 08551 DISQUALIFICATION 7/18/2001
LICKFIELD, KEVIN J. DO 1/19/1962 524 JUSTICE DRIVE MARLTON NJ 08053 DISQUALIFICATION 3/3/2003
LIEBOWITZ, LEONARD J. MD 10/26/1949 5 POE COURT MORGANVILLE NJ 07741 DEBARMENT 8/18/2001
LIFE CARE HOME SERVICES
OF NORTHWESTERN
PENNSYLVANIA DBA GREAT
LAKES HOME HEALTHCARE
SERVICES
1972641496 2127 NORTH 6TH STREET PHILADELPHIA PA 19122 DISQUALIFICATION 12/29/2015
LIFE SUPPORT
CORPORATION
1659699049 CI MOSHANNON VALLEY, 555
GEO DRIVE
PHILLIPSBURG PA 16866 DISQUALIFICATION 12/29/2015
LILLO, CHRISTOPHER T. DMD 10/1/1967 1720150675 191 HIGHWAY 37 WEST TOMS RIVER NJ 08755 DISQUALIFICATION 12/20/2012
LIMIDO, GLEN CARL RPH 11/7/1940 1 EAST PLEASANT AVENUE MAYWOOD NJ 07607 SUSPENSION 10/19/2006
LIMONGELLI, WILLIAM DDS 12/27/1943 1184796534 679 SO. ORANGE AVENUE NEWARK NJ 07106 DISQUALIFICATION 10/30/1986
LINDER, NORBERT MD 4711 BERGENLINE AVENUE UNION CITY NJ 07087 DISQUALIFICATION 3/23/1977
LINK, TIMOTHY MD 10/2/1972 1477767705 63 MONMOUTH PARKWAY MONMOUTH
BEACH
NJ 07750 DISQUALIFICATION 2/5/2018
LIPMAN, CLIFFORD R. MD 1/6/1951 1083676670 26 UNION AVENUE FREEHOLD NJ 07728 DEBARMENT 1/16/2015 5/30/2018
LIPPIELLO, JENNIE A. DC 6/29/1955 1366605966 2920 RT. 23 SOUTH NEWFOUNDLAND NJ 07435 SUSPENSION 4/19/2001
LIPSON, PHILIP A. DO 4/21/1950 38 W. NORTON DRIVE SOUTHAMPTON PA 18966 DISQUALIFICATION 10/19/2005
LIRIANO, ANGELA CHHA 1/4/1959 79 CLINTON AVENUE, APT. #2 JERSEY CITY NJ 07306 DISQUALIFICATION 11/22/2017 PERMANENT
LIRIANO, ANGELA CHHA 1/4/1959 79 CLINTON AVENUE, APT #2 JERSEY CITY NJ 07306 DISQUALIFICATION 7/14/2017
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
75
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
LIRIANO, ANGELA CHHA 1/4/1959 79 CLINTON AVENUE, APT #2 JERSEY CITY NJ 07306 DISQUALIFICATION 4/19/2018
LIVSHITS, BORIS 12/14/1969 1935 83RD STREET APT. E6 BROOKLYN NY 11214 DISQUALIFICATION 8/1/2009
LIVSHITZ PHARMACY INC. 203 16TH AVENUE NEWARK NJ 07103 DISQUALIFICATION 5/21/1980
LIZIK, MICHELLE LPN 1/10/1970 451 FULLERTON AVENUE CAMBRIDGE
SPRINGS
PA 16403 DISQUALIFICATION 11/20/2015
LLANOS, LATOYA CHHA 8/15/1977 433 W. QUINCE STREET VINELAND NJ 08360 DEBARMENT 3/29/2002
LOAIZA, ERIKA CHHA 5/2/1991 206 COVENTRY LANE SOMERSET NJ 08873 DISQUALIFICATION 2/8/2017
LOBO, ANGEL R. MD 12/4/1932 661 14TH AVENUE PATERSON NJ 07504 DEBARMENT 6/11/2002
LOBO, ANGEL R. MD 12/4/1932 398 STEWART AVENUE GARDEN CITY NY 11530 SUSPENSION 5/20/2007
LOBO, MERCY 11/1/1941 22 HELEN PLACE CLIFTON NJ 07011 DISQUALIFICATION 4/23/2007
LOCK, ABRAHAM J. MD 9/5/1941 1801 AVENUE J BROOKLYN NY 12230 DEBARMENT 2/25/2001
LOCURATOLO, LUIS R. MD 12/15/1929 104-01 ROOSEVELT AVENUE CORONA NY 11368 SUSPENSION 12/1/1995
LOGAN, JEANETTE E. RN 9/5/1953 12 ARAGON COURT TRENTON NJ 08628 SUSPENSION 5/20/2004
LOLL-VAN SICKLE, PATRICIA RN 9/27/1953 416 SALEM STREET ELMER NJ 08318 SUSPENSION 4/20/2000
LOPEZ, JOHN J. 3/28/1967 428 N 16TH STREET KENILWORTH NJ 07033 DEBARMENT 12/11/2001
LOPEZ, JOSE A. MD 8/28/1962 1427150846 24 WOODLAND RD. BLOOMFIELD NJ 07003 SUSPENSION 11/20/2006
LOPEZ, JULIANA CHHA 7/8/1987 236 GRAND AVENUE CAMDEN NJ 08105 DISQUALIFICATION 2/8/2017
LOPEZ-FALCONE, JUAN
ANTONIO
8/23/1954 8385 SW 43RD STREET MIAMI FL 33155 DISQUALIFICATION 5/2/2003
LOPRESTI, JACQUELINE A. DO 12/30/1960 1043348220 568 RIDGE RD. FAIR HAVEN NJ 07704 SUSPENSION 12/20/2011
LOPRESTI, JACQUELINE A. DO 12/30/1960 1043348220 FPC ALDERSON ALDERSON WV 24910 DISQUALIFICATION 3/20/2014
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
76
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
LOTTERMAN, RANDEE RN 7/10/1985 6 JUNIATA STREET WEST MILFORD NJ 07480 DISQUALIFICATION 6/15/2017
LOUIS-BAPTISTE, GUERLINE CHHA 5/2/1979 51 LINCOLN STREET EAST ORANGE NJ 07017 DISQUALIFICATION 10/20/2017
LOUISSAINT, PARACLET MD 7/8/1948 1164519179 669 ELIZABETH AVENUE NEWARK NJ 07112 DEBARMENT 1/1/2001 1/11/2017
LOUKHNATI, RAJAA CHHA 10/12/1973 5 COLGATE DRIVE CHERRY HILL NJ 08034 DEBARMENT 2/20/2017
LOVETT, BETTIE CHHA 10/17/1950 212 SENACA TRAIL BROWNS MILLS NJ 08064 DEBARMENT 5/28/2013
LOWREY, RODNEY 2/13/1945 88 3RD AVENUE ATLANTIC
HIGHLANDS
NJ 07716 DISQUALIFICATION
LUCA, BONNIE J. 9/15/1962 1016 WASHINGTON GARDENS WASHINGTON NJ 07882 DEBARMENT 6/10/2007
LUCAS, KATINA RN 4/29/1960 126 LAGUARDIA AVENUE STATEN ISLAND NY 10314 SUSPENSION 10/19/2006
LUDDEN, JAMES W. DPM 2/5/1963 1720054935 23 SOCIETY HILL WAY TINTON FALLS NJ 07724 DISQUALIFICATION 6/8/2007
LUDDEN, JAMES W. DPM 2/5/1963 1720054935 23 SOCIETY HILL WAY TINTON FALLS NJ 07724 DISQUALIFICATION 12/19/2016
LUDWIKOWSKI, MICHAEL RPH 2/18/1972 113 DIXONTOWN ROAD MEDFORD NJ 08055 DISQUALIFICATION 4/13/2018
LUNDY, HOWARD 4/26/1955 1 MALKE DRIVE OCEAN NJ 07712 DEBARMENT 4/4/2015
LYNCH, CHRISTOPHER MD 1/25/1950 1407813975 1719 PENN CROSSING ALLENTOWN PA 18104 DISQUALIFICATION 11/20/2015
LYONS, DANA LPN 4/29/1963 245 4TH AVENUE ROEBLING NJ 08554 SUSPENSION 2/20/2002
LYVAN, KIM DDS 9/19/1955 1346458965 199 CANAL STREET, #201 NEW YORK NY 10013 SUSPENSION 11/27/2000
M & G LIVERY CO., INC. 6 PLEASANT VALLEY WAY WEST ORANGE NJ 08052 SUSPENSION 6/19/2003
M & G TRANSPORTATION
AND LIVERY
269 SHEFFIELD STREET MOUNTAINSIDE NJ 07092 DEBARMENT 10/31/2002
M & M MEDICAL LIVERY 64 BEVAN STREET JERSEY CITY NJ 07306 DISQUALIFICATION 5/31/1994
MAAT, THOMAS P. LPN 10/17/1969 2311 4TH AVENUE TOMS RIVER NJ 08753 SUSPENSION 3/18/2004
MACH, PHILIP C. MD 9/26/1957 1770562993 PO BOX 1000 LORETTO PA 15940 SUSPENSION 5/9/2008
MACH, PHILIP C. MD 9/26/1957 1770562993 30 DANIEL DRIVE FRANKLIN PARK NJ 08823 DISQUALIFICATION 10/7/2008
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
77
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MADDOX, PEARL V. CHHA 9/8/1968 KINSLEY RD. PEMBERTON NJ 08068 DISQUALIFICATION 9/25/2007
MAHAJAN, SHYAM S. MD 3/18/1945 1144496449 7624-A BRISLIN RD, R.D.#7 STROUDSBURG PA 18360 DISQUALIFICATION 12/1/1998
MAHARAJ, GANGARAM RPH 11/23/1957 1326323106 72 VAN REIPEN AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 7/22/2017
MAHGOUB, ADAM 1/1/1961 1995 JFK BLVD., #14 JERSEY CITY NJ 07305 DISQUALIFICATION 6/17/2002
MAHMOOD, SHAHID 4/3/1960 228 GRAND STREET JERSEY CITY NJ 07302 DEBARMENT 3/30/2010
MAHMUD, ASIF MD 2/17/1967 2024 W. 13TH ST. BROOKLYN NY 11223 SUSPENSION 3/18/2004
MAIGUE, LLEWELYN RN 11/30/1960 6 CRYSTAL AVENUE W. ORANGE NJ 07052 SUSPENSION 4/19/2001
MAIN PHARMACY, LLC 1861705873 80 SOUTH MAIN ROAD, SUITE
112
VINELAND NJ 08360 DISQUALIFICATION 4/13/2018
MAIORANO, JOHN RPH 2/13/1951 1659492940 345 UNION HILL RD. ENGLISHTOWN NJ 07726 DISQUALIFICATION 7/11/2000
MAIORANO, JOHN RPH 2/13/1951 1659192940 123 EAST END AVENUE ISLAND HEIGHTS NJ 08732 SUSPENSION 4/18/2002
MAIS, JENNIFER C. PA 12/1/1964 1801035084 22 NEW STREET HILLSDALE NJ 07642 DISQUALIFICATION 4/30/2015
MAKKER, RAM S. MD 4/13/1950 1538117213 52 SNAPDRAGON LANE ROSLYN HEIGHTS NY 11577 DISQUALIFICATION 4/20/2010
MALADY, SUSAN AKA
MAWHINNEY-BRIGNOLA,
SUSAN
RN 3/31/1949 PO BOX 468 BLAIRSTOWN NJ 07825 SUSPENSION 6/20/2001
MALAMUD, YAFIM 2/4/1942 177 SARGEANT AVENUE CLIFTON NJ 07013 DEBARMENT 8/8/2003
MALDONADO, CHEYENNE PHARM
TECH
9/22/1991 3 DUKE DRIVE TOMS RIVER NJ 08757 DEBARMENT 1/5/2017
MALDONADO, SANDRA CHHA 5/9/1970 2808 CONGRESS ROAD CAMDEN NJ 08104 DISQUALIFICATION 3/6/2018
MALDONADO, TOSHIRA CHHA 1/11/1980 4648 THELMA AVENUE MAYS LANDING NJ 08330 DEBARMENT 1/20/2017
MALIK, MOHAMMAD S. 5/15/1960 146 OLD COURTHOUSE RD. MANHASSETT NY 11400 SUSPENSION 9/22/2000
MALIK, MOHAMMAD S. 5/15/1960 146 OLD COURTHOUSE RD. MANHASSETT NY 11040 SUSPENSION 10/20/2002
MALLOY, TIFFANY APN/RN 9/30/1970 1790910503 34 VIBURNUM COURT LAWRENCEVILLE NJ 08648 DEBARMENT 8/28/2017
MALLOZZI, DEBORAH RN 9/9/1964 1603 PERSHING AVENUE FORKED RIVER NJ 08731 DISQUALIFICATION 6/28/2017
MANALO, JERICHO RN 6/30/1989 22 PINE STREET BLOOMFIELD NJ 07109 DISQUALIFICATION 11/13/2017
MANCILLA, MARIA CHHA 6/15/1964 284 REDMOND STREET NEW BRUNSWICK NJ 08873 SUSPENSION 5/14/2007
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
78
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MANCINI, ANGELO D. RPH 8/1/1950 SKEET & DIXONTOWN RD. MEDFORD NJ 08055 DISQUALIFICATION 7/1/1985
MANFRE, MARIA LPN 9/26/1986 262 N. MIDDLESEX COURT THOROFARE NJ 08086 DISQUALIFICATION 6/5/2017
MANGIONE, MICHELE RN 10/24/1954 35 LONGVIEW DRIVE WALDWICK NJ 07363 SUSPENSION 9/20/2004
MANIN, LAWRENCE 611 BURLINGTON MT. HOLLY NJ 08060 DISQUALIFICATION 4/12/1993
MANION, WILLIAM MD 8/12/1952 1134120801 33 MEADOW DRIVE WOODSTOWN NJ 08098 DISQUALIFICATION 3/8/2018
MANKOFF, BERNARD GREEN GROVE RD. NEPTUNE NJ 07753 DISQUALIFICATION
MANNAVA, VENKATA
SRINIVAS
RPH 10/18/1969 1356478895 3300 EAST WEST HIGHWAY HYATTSVILLE MD 20782 DISQUALIFICATION 6/30/2016
MANNING, LUTHER 3/21/1955 586 WEST SCOTT AVENUE RAHWAY NJ 07065 SUSPENSION 10/20/2008
MANNO, MICHAEL DC 5/14/1969 1356704738 PO BOX 1000 FORT DIX NJ 08640 SUSPENSION 10/20/2003
MANSOUR, ALI MD 3/17/1968 1346225885 225 DEMOTT LANE SOMERSET NJ 08873 DEBARMENT 12/20/2014
MANZE, PATRICK MD 7/28/1946 53 GARDNER AVENUE CHATHAM NJ 07928 SUSPENSION 2/20/2005 DECEASED
MANZELLA, JOHN DO 7/15/1964 680 BROADWAY AVENUE PATERSON NJ 07514 DEBARMENT 6/28/2014
MANZI, JOHN J RPH 6 TEMPLE RD., APT 22 C VINELAND NJ 08360 DISQUALIFICATION 6/1/1993
MANZONI, JANET M. DC 4/27/1955 1851497168 52 TENNET RD. MORGANVILLE NJ 07751 SUSPENSION 2/3/1998
MANZONI, JANET M. DC 4/27/1955 1851497168 9 KILMER DRIVE MANALAPAN NJ 07726 DISQUALIFICATION 5/20/2009
MARCELL, JOSEPH A. 305 MAIN ST RIDGEFIELD PARK NJ 07660 DISQUALIFICATION
MARCHAND, ANTHONY MD 11/4/1944 19 DEXTER DRIVE NORTH BASKING RIDGE NJ 07920 SUSPENSION 9/19/2003
MARCHETTA, LEONARD PA 12/5/1966 1720196140 FCI - FORT DIX, PO BOX 2000 JOINT BASE MDL NJ 08640 DISQUALIFICATION 6/3/2016
MARCOS, FRANCISCO RPH 12/10/1975 1699158063 777 CHARNWOOD DRIVE WYCKOFF NJ 07481 DISQUALIFICATION 9/20/2011 4/5/2017
MARCUS, ALAN L. DC 11/22/1951 789 CLIFTON AVENUE CLIFTON NJ 07013 DISQUALIFICATION 7/25/2001
MARKOFF, MORTON DO 10/9/1940 908 FRANCINE DRIVE CHERRY HILL NJ 08003 SUSPENSION 11/7/1997
MARKOSOVA, GRETA CHHA 1/3/1961 2301 WESTMINSTER
BOULEVARD
PARLIN NJ 08859 DISQUALIFICATION 1/31/2017
MARON, ANDREW DDS 6/12/1961 1215035134 326 BROAD STREET RED BANK NJ 07011 DISQUALIFICATION 10/21/2015
MARONPOT, BARBARA DDS 12/20/1953 1821203696 281 MENDHAM ROAD BERNARDSVILLE NJ 07924 DEBARMENT 3/17/2015
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
79
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MARQUEZ, MANUEL S. MD 6/5/1925 112 DOWNING COURT MT. LAUREL NJ 08054 DISQUALIFICATION 12/5/1997
MARQUEZ, OLGA COUNSEL
OR
2827 LINCOLN AVENUE CAMDEN NJ 08105 SUSPENSION 4/29/2003
MARRAZZO-TALLIA,
CHRISTAL
RPH 1/3/1955 406 HARDING RD. FAIRHAVEN NJ 07704 SUSPENSION 10/19/2006
MARSON-FRANCIS, JAVON CHHA 9/16/1993 7810 CORBETT ROAD PENNSAUKEN NJ 08109 DISQUALIFICATION 4/18/2017
MARTIN, ANDRE E. COUNSEL
OR
12/6/1972 127 N. DERBY AVENUE VENTNOR NJ 08406 DEBARMENT 5/24/1999
MARTIN, BENNIE M. COUNSEL
OR
12/19/1964 476 CLIFTON AVENUE CLIFTON NJ 07011 SUSPENSION 5/15/2003
MARTIN, ELLIOTT DPM 9/19/1936 5 HOLLIS RD. E. BRUNSWICK NJ 08816 DISQUALIFICATION 4/22/1991
MARTIN, MARGARET LPN 1/15/1959 207 HEGGEN AVENUE EGG HARBOR TWP. NJ 08234 DISQUALIFICATION 9/8/2017 PERMANENT
MARTIN, PATRICK 11/17/1959 51 HENRY STREET SUCCASUNNA NJ 07876 DISQUALIFICATION 11/20/2015
MARTIN, SUSAN C. LPN/RN 7/8/1961 3421 BRIGHTON STREET PHILADELPHIA PA 19149 SUSPENSION 9/20/2005
MARTINEZ, CINTYA CHHA 8/17/1982 61 CONCORD STREET, APT. 3A JERSEY CITY NJ 07306 DISQUALIFICATION 2/20/2017
MARTINEZ, ELIEZER COUNSEL
OR
11/25/1947 215 SOUTH BURLINGTON RD. BRIDGETON NJ 08302 SUSPENSION 2/20/2006
MARTINEZ, RENATO F. MD 9/1/1948 199 BROAD ST., SUITE 1-A BLOOMFIELD NJ 07003 SUSPENSION 8/5/1997
MARTINEZ, SUZETTE CHHA 12/26/1966 52 FOREST GLEN DRIVE HIGHLAND PARK NJ 08904 DISQUALIFICATION 7/31/2017
MARTINIQUE, BURTON OD 3/27/1935 1942370945 2 SHEFFIELD DRIVE WILLINGBORO NJ 08046 DEBARMENT 4/18/2016
MARTIROSOV, ALEKSANDR DO 8/19/1963 1700931185 1084 BRIAR WAY FORT LEE NJ 07024 DISQUALIFICATION 11/20/2017 5/30/2018
MARTORANO, JOSEPH RPH 8/13/1935 1248 STANWOOD STREET PHILADELPHIA PA 19100 DISQUALIFICATION 6/1/1993
MARUCCI, DONATO MD 11/14/1955 14 FRANKLIN STREET BELLEVILLE NJ 07109 DISQUALIFICATION 9/28/1999
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
80
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MARURI, NAGESWARA
REDDY RPH 3/20/1952 1083932495 8 REDWOOD AVENUE WEST ORANGE NJ 07052 DISQUALIFICATION 2/11/2016
MASCOLO, JOSEPHINE RN 6/4/1949 1814 KENNEDY BLVD. UNION CITY NJ 07087 DEBARMENT 4/7/2004
MASI, JAMES COUNSEL
OR
10/4/1947 1518046226 631 OCEAN AVENUE, APT.304 BRADLEY BEACH NJ 07720 DEBARMENT 2/20/2013
MASON, JAMES I. 8/7/1926 702 SUNSHINE LAKES DRIVE VOORHEES NJ 08043 SUSPENSION 2/23/2000
MASON, SYDELLE 9/19/1942 702 SUNSHINE LAKES DRIVE VOORHEES NJ 08043 SUSPENSION 2/23/2000
MASOOD, MARUK 3/14/1968 1 CHESTERFIELD DRIVE WARREN NJ 07059 DISQUALIFICATION 11/20/2012
MASOOD, YOUSUF MD 4/19/1964 1235343138 PO BOX 8000 BRADFORD PA 16701 DISQUALIFICATION 11/20/2012
MASRI, NASSER M. DDS 2/1/1966 360 GETTY AVENUE PATERSON NJ 07503 SUSPENSION 10/19/2000
MASSARO, DONNA M. THERAPIS
T
11/24/1959 205 RIVA DRIVE, APT. 24 HACKETTSTOWN NJ 07840 SUSPENSION 11/20/2008
MASTRANGELO, MARTHA LPN 12 NORTH 28TH AVENUE LONGPORT NJ 08403 DISQUALIFICATION 6/1/1993
MASTRIA, ERNEST PSYCH 12/6/1947 213 9TH AVENUE BELMAR NJ 07719 DISQUALIFICATION 8/18/2011
MASTROKOSTAS,
ANTHANASIOS
RPH 1/29/1973 1861769481 11 EQUINOX LANE FREEHOLD NJ 07728 DISQUALIFICATION 10/15/2009
MATALON, VIVIENNE MD 4/19/1956 1396858635 1 NORTH SYRACUSE DRIVE CHERRY HILL NJ 08034 DISQUALIFICATION 12/19/2016
MATALON, VIVIENNE MD 4/19/1956 1396858635 1 NORTH SYRACUSE DRIVE CHERRY HILL NJ 08034 DEBARMENT 10/31/2016
MATHEW, REX MD 8/27/1975 1336164862 2301 SOUTH BROAD STREET PHILADELPHIA PA 19148 DISQUALIFICATION 1/2/2017
MATHEW, REX MD 8/27/1975 1336164862 17608 PRINCE EDWARD DRIVE OLNEY MD 20832 DISQUALIFICATION 4/4/2018
MATRISS, JOSEPH P. DDS 7/3/1923 1700013554 337 HENRY STREET HASBROUCK
HEIGHTS
NJ 07604 SUSPENSION 9/18/2003
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
81
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MATRISS, JOSEPH P. DDS 7/3/1923 1700013554 337 HENRY STREET HASBROUCK
HEIGHTS
NJ 07604 DEBARMENT 10/9/2007
MATTERN, JILL MD 3/12/1961 1669514253 20 WILSON TERRACE, APT. 1 STATEN ISLAND NY 10304 DEBARMENT 11/29/2015
MATTHEWS, BHA'SHEER CHHA 6/24/1994 16 HEMLOCK WALK CAMDEN NJ 08104 DISQUALIFICATION 4/18/2017
MATURA, DENISE RN 9/27/1969 1001 LINDEN AVENUE BRICK NJ 08723 SUSPENSION 10/26/1999 7/20/2012
MATURA, WILLIAM DC 11/7/1943 PO BOX 7000 FORT DIX NJ 08640 SUSPENSION 12/20/2006
MATZ, RODNEY S. MD 2/6/1942 43 MACDONALD DRIVE WAYNE NJ 07470 DISQUALIFICATION 12/29/1995
MAUGLE, BARBARA DPM 7/30/1963 800 HILLSIDE AVENUE WESTFIELD NJ 08901 DISQUALIFICATION 1/10/2001
MAUIRI, SANDY LPN 6/20/1958 34 FRANKLIN PL. TOTOWA NJ 07512 SUSPENSION 6/20/2005
MAXVITAT, KATHLEEN E. PHARM
TECH
5/8/1986 200 W. MERCHANTS STREET AUDUBON NJ 08106 SUSPENSION 4/20/2011
MAXYMIV, NICOLAI 3/13/1971 3 PARKWOOD DRIVE SOUTH AMBOY NJ 08879 DISQUALIFICATION 7/10/2003
MAYER, FREDERICK G. DC 6/17/1953 1811082894 610 WOODLAND AVENUE AVON BY THE SEA NJ 07717 DISQUALIFICATION 8/20/2000 9/21/2011
MAYS, CYNTRICE CHHA 7/11/1984 98 OAK STREET CLEMENTON NJ 08021 DISQUALIFICATION 9/19/2017
MAYS, ROBERT E. 6/26/1977 6133 HANLON STREET CAPITAL HEIGHTS MD 20743 DISQUALIFICATION 10/31/2017
MAZUR, BONNIE DMD 1/21/1961 210 E. SEAVIEW AVENUE LINWOOD NJ 08221 SUSPENSION 1/27/1998
MAZZACCOS PHARMACY
INC.
427 PROSPECT STREET LONG BRANCH NJ DISQUALIFICATION 7/27/1983
MCAFEE, JORDAN CHHA 7/24/1987 13 FAIRWAY COURT MARLTON NJ 08053 DISQUALIFICATION 7/20/2017
MCCABE, VALERIE A. LPN 1/21/1964 830 CHESTNUT STREET KEARNY NJ 07032 SUSPENSION 9/20/2004
MCCALL, ELDORA CHHA 1/7/1965 OLD CRANBURY RD. CRANBURY NJ 08512 SUSPENSION 9/20/2007
MCCARVILLE, MICHAEL MD 8/21/1956 1871666321 1020 IRVING AVENUE ENDICOTT NY 13760 DISQUALIFICATION 11/20/2015
MCCASKILL, CAMMY 11/3/1970 6518 BOBOLINK PLACE PHILADELPHIA PA 19142 DISQUALIFICATION 11/20/2015
MCCASKILL, JACQUELINE CHHA 6/20/1963 34 36 12TH AVENUE PATERSON NJ 07524 DISQUALIFICATION 10/15/2004
MCCOLGAN, PETER DMD 3/30/1946 RR 1, PO BOX 29 TANNERSVILLE PA 18372 SUSPENSION 6/19/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
82
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MCCOLGAN, PETER DMD 3/30/1946 35 OLD WOLFE ROAD BUDD LAKE NJ 07828 DEBARMENT 5/13/1999
MCCREA, NIOME CHHA 1/11/1989 63 VILLAGE DRIVE BARNEGAT NJ 08005 DISQUALIFICATION 9/26/2017
MCDANIELS, HOLLY RN 1/4/1988 111 COUNTRYSIDE DRIVE MYRTLE BEACH SC 29579 DISQUALIFICATION 6/28/2017
MCDONALD, JOSEPH MD 8/17/1933 2052 MORRIS AVENUE UNION NJ 07083 DEBARMENT 9/21/1999
MCDONALD, KEITH THERAPIS
T
7/7/1954 2220 MEADOW LANE,
APT.D26
SECAUCUS NJ 07094 DISQUALIFICATION 2/20/2001
MCDONALD, RHONDA RN 8/20/1970 962 GROVE STREET IRVINGTON NJ 07111 SUSPENSION 1/18/2007
MCDONALD-HASWELL,
EVERSLEY
6/10/1955 52 ELM STREET MONTCLAIR NJ 07042 SUSPENSION 4/18/2002
MCDOWELL, SHASHAWN CHHA 5/25/1994 25 WILLIAM STREET, 2ND FL LITTLE FALLS NJ 07424 DEBARMENT 12/6/2017
MCELROY, DONALD J. DDS 9/14/1923 14 RESERVOIR AVENUE DOVER NJ 07801 DISQUALIFICATION 2/20/1983
MCFADDEN, TIKEYA CHHA 2/13/1991 526 RAND STREET CAMDEN NJ 08105 DISQUALIFICATION 2/8/2017
MCGAVIN, CAMERON
LINDSAY
PSYCH 11/9/1969 1760408041 417 BOYD STREET TURTLE CREEK PA 15145 DISQUALIFICATION 3/27/2015
MCGEE, ELIZABETH RN 8/25/1957 51 VAN DUYNE AVENUE WAYNE NJ 07470 SUSPENSION 2/20/2002
MCGEE, JOHN MD 5/8/1958 1811991284 1160 KENNEDY BOULEVARD BAYONNE NJ 07002 DEBARMENT 9/6/2016
MCGILL, WINSTON MD 4/4/1947 1093810749 258 CENTRAL AVENUE ORANGE NJ 07050 DEBARMENT 10/16/2014
MCGINNIS, GEORGE J. 119 ADELINE ST TRENTON NJ 08611 DISQUALIFICATION 10/16/1986
MCGINTY, JAMIE RN 5/9/1978 251 DEVON ROAD TOWNSHIP OF
WASHINGTON
NJ 07676 DISQUALIFICATION 7/22/2017
MCGLOSTER, CARL L. DDS 12/5/1965 1962517839 90 TIFFANY BOULEVARD NEWARK NJ 07104 DISQUALIFICATION 5/20/2007
MCGRATH, HELEN J. RN 6/20/1950 6 BLAIR RD. KENDALL PARK NJ 08824 SUSPENSION 10/20/2005
MCINTYRE, JOHN G. DDS 10/8/1957 1487740718 1301 PENN AVENUE WYOMISSING PA 19610 DEBARMENT 6/22/2002 12/2/2011
MCKEAN JR., JOSEPH MD 7/14/1941 2601 MEADOW VIEW RD. EDMOND OK 73013 DISQUALIFICATION 5/15/2000
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
83
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MCKEITHAN, SHAVONNE LPN 1/31/1972 259 SECOND STREET HACKENSACK NJ 07601 DISQUALIFICATION 6/5/2017
MCKNIGHT, BOBBY 3/14/1986 4543 NORTH GRATZ STREET PHILADELPHIA PA 19140 DISQUALIFICATION 11/20/2015
MCLAUGHLIN, KELLY M. LPN 12/27/1971 SANDYBROOK RD. MANALAPAN NJ 07726 SUSPENSION 8/20/2008
MCLEAN, EDWARD 506 MONTICELLO COURT MARLTON NJ 08053 SUSPENSION 7/18/2002
MCLEISH, FREDERICK RPH 7/11/1962 1447461505 5 WINDSOR DRIVE EGG HARBOR TWP. NJ 08234 DISQUALIFICATION 7/19/2017 PERMANENT
MCMAHON, THOMAS MD 11/2/1944 1952309742 121 WARWICK ROAD HADDONFIELD NJ 08033 DEBARMENT 2/15/2016 PERMANENT
MCMURTRY-BURRELL,
DIANE
RPH 10/6/1965 1609015015 MDC BROOKLYN BROOKLYN NY 11232 DISQUALIFICATION 5/20/2015
MCMURTRY-BURRELL,
DIANE
RPH 10/6/1965 1609015015 MDC BROOKLYN, PO BOX
329002
BROOKLYN NY 11232 DISQUALIFICATION 11/20/2015
MCPHERSON, KIMBERLY CHHA 5/14/1987 110 THOMAS AVENUE LAWNSIDE NJ 08045 DISQUALIFICATION 2/8/2017
MCPHERSON, M. LEEANNE RPH 12/27/1971 269 HAMPTON STREET BRIDGETON NJ 08302 SUSPENSION 3/7/2008
MCQUEEEN, BRITTANY CHHA 10/18/1987 807 N. INDIANA AVENUE ATLANTIC CITY NJ 08401 DISQUALIFICATION 1/23/2018
MCRAE, CHANEL CNA 4/27/1978 448 RAILROAD BLVD. RICHLAND NJ 08350 DISQUALIFICATION 2/23/2006
MEDICAL CLINICAL
LABORATORIES
373 LIVINGSTON AVENUE NEW BRUNSWICK NJ 08901 DISQUALIFICATION 7/29/1999
MEDIPATH EXPRESS 666 PLAINSBORO ROAD PLAINSBORO NJ 08536 DISQUALIFICATION 1/14/2005
MEDISCOPE DIAGNOSTIC
LAB
1250 PARK AVENUE PLAINFIELD NJ 07060 SUSPENSION 11/16/1998
MEDVEDIK, YELENA 10/15/1972 2 HICKORY HILLS COURT HOLMDEL NJ 07733 DISQUALIFICATION 10/3/2013
MEISHER, VLAD A. PSYCH 9/23/1939 HILLSIDE TERR. FAIR LAWN NJ 07410 DISQUALIFICATION 8/10/2007
MEISHER, VLAD A. PSYCH 9/23/1939 15-07-PLAZA RD., APT. A FAIRLAWN NJ 07410 DISQUALIFICATION 8/1/2009
MELENDEZ, JUANITA COUNSEL
OR
6/16/1938 NORTH 35TH STREET CAMDEN NJ 08105 SUSPENSION 4/29/2003
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
84
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MELENDEZ, LIZZADY CHHA 12/2/1984 602 SOUTH 4TH STREET CAMDEN NJ 08103 DISQUALIFICATION 1/26/2018
MELKER, NEIL L. DDS 11/7/1956 1053443705 219 VALLEY RD. PRINCETON NJ 08540 DISQUALIFICATION 1/23/2009
MELTZER, SCOTT M. DMD 1/4/1964 1366561425 70 WELLESLEY WAY FREEHOLD NJ 07728 DISQUALIFICATION 4/17/2014
MELTZER, SCOTT M. DMD 1/4/1964 1366561425 70 WELLESLEY WAY FREEHOLD NJ 07728 DEBARMENT 5/3/2013
MEMBER, BERNARD J. MD 1/29/1948 12335 S. ANNA DRIVE ROCKVILLE MD 23146 SUSPENSION 5/20/2004
MENDEL, RICHARD 6/1/1961 1306939202 701 SO. HOWARD AVENUE,
SUITE 106
TAMPA FL 33606 DISQUALIFICATION 12/29/2015
MENDEZ, EDELFONSO DO 11/16/1964 SMITH AVENUE NORTH BERGEN NJ 07047 DISQUALIFICATION 3/20/2008
MENDEZ, NORMA CHHA 2/6/1967 60 BALDWIN STREET, #2 NEW BRUNSWICK NJ 08901 DISQUALIFICATION 2/20/2017
MENSAH-NARH, STEVEN RPH 5/29/1962 WEDGEWOOD DRIVE NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 2/20/2007
MEO, JOHN RPH 8/11/1954 1427086818 149 BOWNE RD. WAYSIDE NJ 07712 DISQUALIFICATION 5/27/2009
MERVIL, DARLENE CHHA 9/20/1988 122 ROSSITER AVENUE PATERSON NJ 07502 DEBARMENT 5/31/2018
MESA, NELSON PCA 3/28/1944 964 GROVE STREET, APT. A ELIZABETH NJ 07202 DISQUALIFICATION 4/17/2017
MESSICK, PAULA LPN 1/28/1957 105 SUMMIT AVENUE EWING NJ 08628 DISQUALIFICATION 6/18/2009
MESSO, RALPH MD 9/3/1961 1184798621/
1255309175
2 RICHMONDE COURT COLTS NECK NJ 07722 DEBARMENT 5/28/2015
METTEAUX, IYANNAH CHHA 3/24/1989 46 N. ARLINGTON AVENUE EAST ORANGE NJ 07017 DISQUALIFICATION 2/8/2017
METZ, DANIEL 7/11/1980 FCI OTISVILLE #66799-050 OTISVILLE NY 10963 DISQUALIFICATION 7/20/2015
MEYER, CYNTHIA RN 12/12/1963 8200 KENNEDY BOULEVARD NORTH BERGEN NJ 07047 DISQUALIFICATION 2/20/2018
MEYER, GLORIA KINGS HIGHWAY MIDDLETOWN NJ 07748 DISQUALIFICATION 6/1/1993
MEYER, JOSEPH KINGS HIGHWAY MIDDLETOWN NJ 07748 DISQUALIFICATION 6/1/1993
MEYERLE, GISELA LPN 8/4/1966 1356538169 705 SUNFLOWER AVENUE LANGHORNE PA 19047 DISQUALIFICATION 2/28/2018
MEZERENEZ, MARIA CHHA 7/8/1986 33 ASPEN PLACE PASSAIC NJ 07055 DISQUALIFICATION 3/6/2018
MGBEME, FESTUS RPH 8/22/1954 882 BROAD STREET NEWARK NJ 07114 DISQUALIFICATION 3/8/2001
MICHAIL, MEDHAT DDS 10/17/1959 848 BERGEN AVENUE JERSEY CITY NJ 07306 SUSPENSION 4/29/1998
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
85
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MIKHAIL, PETER RPH 11/11/1978 48 FALLON AVENUE ELMONT NY 11003 DISQUALIFICATION 11/18/2004
MIKOS, KRISTEN RN 6/8/1979 2111 PRINCETON PIKE PHILADELPHIA PA 19149 DISQUALIFICATION 5/2/2017
MIKSIS, MARY E. RN 12/5/1958 126 WINSTEAD DRIVE WESTAMPTON NJ 08060 DISQUALIFICATION 2/17/2004
MIL, PAUL 11/2/1949 USP LEWISBURG, PO BOX
1000
LEWISBURG PA 17837 DISQUALIFICATION 2/9/2017
MILAROLA CORPORATION 57 BROADWAY NEWARK NJ 07014 DISQUALIFICATION
MILLER, DEBBIE L. DO 6/6/1949 1750561866 94 EAST WATER ST TOMS RIVER NJ 08753 DEBARMENT 4/26/2002 DECEASED
MILLER, DEIDRE T. 12/23/1962 20 PERENNIAL LANE WILLINGBORO NJ 08046 DISQUALIFICATION 7/19/2001
MILLER, DEIDRE T. 12/23/1962 92 RITTENHOUSE DRIVE WILLINGBORO NJ 08046 DISQUALIFICATION 3/29/2000
MILLER, JOSEPH M. DO 4/19/1971 1255307856 9 VICTORIA CIRCLE JACKSON NJ 08527 DISQUALIFICATION 8/20/2015
MILLER, JUSTIN PSYCH 2/1/1981 1952594921 616 DALE COURT WEST RIVERVALE NJ 07675 DISQUALIFICATION 1/2/2017 PERMANENT
MILLER, RANDALL DO 1/3/1952 1740342575 1015 VAN HOUTEN AVENUE CLIFTON NJ 07013 DISQUALIFICATION 1/1/2001 4/6/2017
MILLER, ROY C. 703 WEST SHORE TRAIL LAKE MOHAWK NJ 07871 DISQUALIFICATION 6/1/1993
MILLER, SANDRENE A. MD 11/19/1948 1912192527 50 UNION AVENUE, SUITE 401 IRVINGTON NJ 07111 SUSPENSION 2/25/1998
MILLER, SANDRENE A. MD 11/19/1948 1912192527 202 ELMWYND DRIVE ORANGE NJ 07050 SUSPENSION 7/22/1999
MILLET, CYNTHIA CHHA 6/10/1993 104 ROUTE 46 EAST ELMWOOD PARK NJ 07407 DEBARMENT 8/24/2017
MILMAN, BORIS 3/3/1951 655 AMBOY AVENUE WOODBRIDGE NJ 07095 DISQUALIFICATION 9/11/2001
MILORADOVICH, VADIM MD 5/11/1944 58 MERCER AVENUE HARTSDALE NY 10530 DISQUALIFICATION 11/20/2013
MILVIHILL, CHELSIE CHHA 11/5/1990 501 MAPLE STREET LAKEHURST NJ 08733 DEBARMENT 12/18/2017
MIMS, CAROLE 9/30/1946 1058 WILLOW STREET NORRISTOWN PA 19401 DISQUALIFICATION 11/20/2015
MINATEE, SHERAI LPN 1/2/1980 509 WARWICK ROAD LAWNSIDE NJ 08045 DISQUALIFICATION 3/15/2018
MINNOW, MARY CHHA 7/10/1958 9 WINDINGWOOD DRIVE SAYREVILLE NJ 08872 DISQUALIFICATION 7/25/2001
MIRAGLIA, ROBERT LCSW 10/1/1954 254 VOSE AVENUE SOUTH ORANGE NJ 07079 SUSPENSION 5/9/2002
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
86
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MIRANDA, MEREDITH RPH 1/2/1983 1053740993 3204 BLUE MOUNTAIN LANE NAZARETH PA 18064 DISQUALIFICATION 10/25/2016
MIRILASHVILI, MOSHE B. MD 6/15/1948 1427081223 PO BOX 350146 BROOKLYN NY 11235 DISQUALIFICATION 11/17/1999
MISHRA, ARUNA MD 8/10/1938 63 WEST BROADWAY SALEM NJ 08079 DISQUALIFICATION 2/4/1997
MISHRA, ARUNA MD 8/10/1938 317B AUBURN RD. PILESGROVE NJ 08098 DEBARMENT 1/3/2000
MITRA, RANAJIT MD 1/12/1952 1417096942 2366 ST. GEORGES AVENUE RAHWAY NJ 07065 DEBARMENT 10/12/2014
MITRA, RANAJIT MD 1/12/1952 1417096942 2366 ST. GEORGES AVENUE RAHWAY NJ 07065 DISQUALIFICATION 7/20/2015
MITRESKI, IGOR MD 6/20/1978 1629305255 10 IVY LANE WALLINGTON NJ 07057 DISQUALIFICATION 3/26/2015
MITSUI, MASAO MD 6/19/1939 9 BRIARWOOD RD. JERSEY CITY NJ 07305 SUSPENSION 12/20/2001
MOCKOVIAK, PATRICIA LPN 10/5/1954 5 BEECH STREET EDISON NJ 08817 SUSPENSION 2/19/2004
MODICA, JOSEPH CHHA 6/4/1979 82 JEFFERSON STREET SOUTH BOUND
BROOK
NJ 08880 DISQUALIFICATION 1/31/2017
MOHAMED, ASHLI CHHA 11/29/1990 104 FOUNTAIN AVENUE TRENTON NJ 08618 DISQUALIFICATION 1/31/2017
MOHAMED, HASHIM H. 5/13/1965 PO BOX 8332 JERSEY CITY NJ 07308 DISQUALIFICATION 4/12/1994
MOHAMMAD, OMAR RPH 11/3/1977 1053580068 15 GRIST MILL LANE UPPER SADDLE
RIVER
NJ 07458 DISQUALIFICATION 1/20/2012 5/17/2018
MOHAMMAD, OMAR RPH 11/3/1977 1053580068 15 GRISTMILL LANE UPPER SADDLE
RIVER
NJ 07458 DISQUALIFICATION 9/20/2012 5/17/2018
MOJICA, MARIA CHHA 11/27/1989 108 BEECH STREET PATERSON NJ 07501 DISQUALIFICATION 1/31/2017
MOLDAVER, INNA 1/19/1948 32 BEECHWOOD AVENUE EDISON NJ 08837 DEBARMENT 2/17/2016
MOLINA, DANIEL RPH 8/29/1961 320 EAST 42ND STREET, APT.
618
NEW YORK NY 10017 DISQUALIFICATION 6/28/2017
MONFORTO, CHRISTINE RN 7/6/1984 2620 HAMILTON DRIVE VOORHEES NJ 8043 DISQUALIFICATION 12/29/2015
MONICA, JULIANNE H. DC 4/12/1957 1235372608 509 ESSEX AVENUE SPRING LAKE NJ 07762 SUSPENSION 2/20/2002
MONSUL, ROBERT W. MD 6/1/1931 301 NORTH MAIN STREET MANVILLE NJ 08835 DISQUALIFICATION 5/10/1990
MONTES, NANCY CHHA 5/21/1966 17-20 WELL DRIVE FAIR LAWN NJ 07410 DISQUALIFICATION 8/1/2017
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
87
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MOON, RASHIKA RN 6/17/1970 2 JASON CIRCLE PENNS GROVE NJ 08069 DISQUALIFICATION 6/28/2017
MOONEY, MARY MELISSA LPN 5/24/1973 777 CHERRY TREE RD. ASTON PA 19014 DISQUALIFICATION 4/23/2007
MOOR, JEAN RN 1/19/1956 100 COLONIAL WAY ALIQUIPPA PA 15001 DISQUALIFICATION 11/20/2015
MOORE, BRITTANY CHHA 2/28/1994 141 BORDEN AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 7/14/2017
MOORE, JANE A. RN 2/27/1962 235 KINGS RD. MADISON NJ 07940 SUSPENSION 5/19/2005
MOORE, JONATHAN R. MD 4/23/1917 19 N. PEARL STREET BRIDGETON NJ 08302 DISQUALIFICATION 8/19/1997
MOORE, LILLIE, R. 8/31/1961 353 S. CENTER ST., APT. 19 ORANGE NJ 07050 SUSPENSION 10/20/2002
MOORE, LYNDA A. LPN 1/13/1968 10719 JUREL CT. W. APT. B LAKEVILLE MN 55044 SUSPENSION 1/19/2005
MOORJANI, KAMAL RPH 7/3/1970 217 VAN BUREN STREET LYNDHURST NJ 07071 DISQUALIFICATION 6/1/2010 8/26/2016
MOORMANN, BARBARA
ANN
CHHA 11/3/1947 2467 BREATHSTONE DRIVE POWELL OH 46065 DISQUALIFICATION 2/20/2017
MORALES SR., OSVALDO 8/26/1948 78 W. 180TH STREET, 2ND FL BRONX NY 10453 SUSPENSION 4/13/2008
MORALES SR., OSVALDO 8/26/1948 78 W. 180TH STREET BRONX NY 10453 DISQUALIFICATION 9/16/2011
MORALES, ARLENE 3/18/1956 254 NORTH 7TH STREET NEWARK NJ 07107 SUSPENSION 9/19/2002
MORALES, CHRISTINO 8/22/1964 328 MARKET STREET CAMDEN NJ 08102 SUSPENSION 10/5/2000
MORALES, CHRISTINO 8/22/1964 PO BOX 26883 PHILADELPHIA PA 19134 SUSPENSION 7/2/2003
MORALES, FERNANDO CNA 2/18/1981 346 S. MAIN STREET PHILLIPSBURG NJ 08865 SUSPENSION 12/21/2004
MORALES, JAMES MD 3/8/1970 1386649507 2319 CRYSTAL MILE COURT TOMS RIVER NJ 08755 SUSPENSION 1/11/2016
MORALES, JAMES MD 3/8/1970 1386649507 16 WOODVIEW DRIVE HOWELL NJ 07731 DISQUALIFICATION 11/30/2017
MORALES, JUSTINA CHHA 4/7/1991 62 HIGH STREET WOODBURY NJ 08096 DISQUALIFICATION 2/8/2017
MOREL, MARIA CHHA 5/25/1974 735 TWENTY SECOND STREET PATERSON NJ 07504 DISQUALIFICATION 7/14/2017
MORELAND, CHARLOTTE CHHA 1/21/1965 121 PROSPECT VILLAGE, APT.
A
TRENTON NJ 08618 DISQUALIFICATION 4/29/2008
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
88
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MORELAND, CHARLOTTE CHHA 1/21/1965 121 PROPECT VILLAGE, APT. A TRENTON NJ 08618 SUSPENSION 9/20/2008
MORELLI, TIMOTHY J. RPH 10/28/1955 801 BUTLER PIKE MERCER PA 16137 SUSPENSION 5/19/2005
MORELOS, LISA A. RN 3/14/1965 162 SHENANDOAH BLVD. TOMS RIVER NJ 08753 SUSPENSION 6/19/2003
MORENO, BARTOLO COUNSEL
OR
6/27/1959 2221 38TH STREET PENNSAUKEN NJ 08110 SUSPENSION 4/29/2003
MORERA, JESSICA CHHA 12/31/1981 116 DALTON STREET ROSELLE PARK NJ 07204 DISQUALIFICATION 2/8/2017
MORGANSTEIN, HENRY DO 9/14/1939 1689730343 774 CARTERET COURT MT. LAUREL NJ 08054 DISQUALIFICATION 11/23/2010
MORGANSTEIN, HIRAM N. OD 9/26/1918 5618 BERGENLINE AVENUE WEST NEW YORK NJ 07093 DEBARMENT 2/22/2001
MORIARTY, JACK 4/4/1952 312 GRANDE RIVER BLVD. TOMS RIVER NJ 08755 SUSPENSION 4/8/1999
MORRIS, CHRISTINE CHHA 12/3/1984 323 KAIGHN AVENUE CAMDEN NJ 08103 DISQUALIFICATION 5/16/2018
MORRISON, JAMES C. MD 2/13/1927 RADIO RD AT EAST BOAT TUCKERTON NJ 07087 DISQUALIFICATION 6/1/1993
MORTON, MARION RPH 3/3/1966 2321 SPRUILL AVENUE, APT.
917
NORTH
CHARLESTON
SC 29405 DEBARMENT 2/6/2012
MOSHKOVITCH, VASIL MD 4/22/1955 1326116419 41 NAUTILUS DRIVE MANAHAWKIN NJ 08050 DISQUALIFICATION 11/22/2016 PERMANENT
MOSHKOVITCH, VASIL MD 4/22/1955 1326116419 41 NAUTILUS DRIVE MANAHAWKIN NJ 08050 DISQUALIFICATION 3/3/2017 PERMANENT
MOSKOWITZ, MYRON DPM 1/21/1942 705 RIDGE DRIVE UNION NJ 07083 SUSPENSION 11/20/2006
MOSS, ALBERT H. MD 10/20/1940 28 BARTLE RD. SOMERSET NJ 08873 SUSPENSION 5/19/2005
MOSS, ROBERT H. DPM 5/15/1968 1881716348 244 N. MAIN STREET MULLICA HILL NJ 08062 DEBARMENT 11/2/2011
MOSS, ROBERT H. DPM 5/15/1968 1881716348 FCI OTISVILLE, PO BOX 1000 OTISVILLE NY 10963 DISQUALIFICATION 11/20/2015
MOSS, ROBERT H. DPM 5/15/1968 1881716348 244 NORTH MAIN STREET MULLICA HILL NJ 08062 DISQUALIFICATION 2/20/2013
MOSSAVI, AHMAD MD 11/8/1944 1629046248 7 MALKE DRIVE OCEAN NJ 07712 DEBARMENT 2/23/2012
MOTA, KAESHA CHHA 1/2/1994 433 N. 7TH STREET CAMDEN NJ 08102 DISQUALIFICATION 7/14/2017
MOTT, TARA RN 2/28/1982 3557 SHARON RD. WEST MIDDLESEX PA 16159 DISQUALIFICATION 11/20/2015
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
89
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MOULDER, DARIA PHARM
TECH
1/16/1962 2715 BAYSHORE RD. VILLAS NJ 08251 DISQUALIFICATION 4/20/2010
MOUNT LAUREL CENTER
FOR REHAB AND
HEALTHCARE
1851669287 3718 CHURCH ROAD MOUNT LAUREL NJ 08054 DISQUALIFICATION 7/16/2017
MOURACHOV, PAVEL 8/26/1971 1083711121 3917 WEST ROAD, SUITE 137 LOS ALAMOS NM 87544 DISQUALIFICATION 12/29/2015
MOZULAY, MARK J. MD 6/23/1957 1669631719 512 TOWNSHIP LANE BLUE BELL PA 19422 SUSPENSION 12/1/1998
MUHAMMAD, ABDUL B. MD 3/4/1964 284 BROADWAY NEWARK NJ 07104 DISQUALIFICATION 11/8/2004
MUHAMMAD,
DIAMONNIQUE
CHHA 3/10/1992 354 7TH AVENUE WEST NEWARK NJ 07107 DISQUALIFICATION 7/14/2017
MUID, JANNAH 1/3/1984 671 LINCOLN AVENUE ORANGE NJ 07050 DISQUALIFICATION 11/18/2010
MUISE, NICOLLETE CHHA 11/3/1990 172 FRANKLIN ROAD DENVILLE NJ 07834 DISQUALIFICATION 11/8/2017
MUKHTAR, JUNAID 9/6/1960 114 BALDWIN AVENUE JERSEY CITY NJ 07306 SUSPENSION 6/5/1997
MULLANGI, KUMAR R. MD 12/9/1965 SOUTH BROADWAY STREET BURLINGTON IA 52601 SUSPENSION 5/20/2008
MULLIGAN, RACHEL M. 2/7/1978 241 HAWAII DRIVE BRICK NJ 08723 DISQUALIFICATION 4/11/2008
MULTANI, GURMEET PSYCH 4/14/1955 1528225406 1055 CALLE DE LAS PALM REDLANDS CA 92373 DISQUALIFICATION 6/9/2011
MUNGEN, JONETTA V. CHHA 9/30/1972 34 VERMONT AVENUE NEWARK NJ 07106 SUSPENSION 6/20/2001
MUNN, DONIELLE CHHA 5/26/1984 150 HOME AVENUE, FL. 2 TRENTON NJ 08611 DISQUALIFICATION 2/8/2017
MUNOZ, GUILLERMO DO 1/20/1965 1023071669 824 ELIZABETH AVENUE ELIZABETH NJ 07201 DEBARMENT 11/25/2015 5/13/2016
MUNOZ, JULIO ANTHONY 1/22/1965 4 NORMAL AVENUE UPPER MONTCLAIR NJ 07043 DEBARMENT 10/26/2006
MUNSIF, ANAND MD 11/10/1956 1982879805 127 E. NORTHFIELD RD. LIVINGSTON NJ 07039 DEBARMENT 11/7/2011
MUNZEL, GREGORY
THOMAS
3/5/1976 140 WAPPOO CREEK DRIVE CHARLESTON SC 29412 DEBARMENT 4/22/2012
MURRAY, LAKIRAH LPN 10/2/1985 1311 NE 77TH AVENUE GAINESVILLE FL 32609 DEBARMENT 1/5/2018
MURRY JR., TOMMIE 11/20/1958 2697 RAVEN RD. CINNAMINSON NJ 08077 SUSPENSION 5/25/1999
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
90
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
MURRY JR., TOMMIE 11/20/1958 2697 RAVEN RD. CINNAMINSON NJ 08077 DEBARMENT 1/5/2001
MURRY JR., TOMMIE 11/20/1958 2697 RAVEN RD. CINNAMINSON NJ 08077 DEBARMENT 10/20/2002
MUSARRA, GERALD C. DMD 1/3/1920 525 WASHINGTON AVENUE HOBOKEN NJ 07030 DISQUALIFICATION
MUSCIO, ROBERT MD 9/8/1973 1578510723 333 BROAD STREET RED BANK NJ 07701 DISQUALIFICATION 3/19/2015
MYERS, HOWARD MD 10/30/1939 103 FAIRWAY TERRACE MOUNT LAUREL NJ 08054 DISQUALIFICATION 12/1/1998
MYNDIUK, JAROSLAW MD 4/19/1910 96 TUXEDO PARKWAY NEWARK NJ 07106 DISQUALIFICATION 2/27/1988 DECEASED
NAGLE, BRITTANY RN 1/13/1988 709 NORTH VICTORIA AVE. VENTNOR CITY NJ 00840 DISQUALIFICATION 10/25/2016
NAIMOLI, DANIELLE 7/8/1979 824 HOLIDAY COURT TOMS RIVER NJ 08753 SUSPENSION 9/30/2005
NALBONE, PHILLIP C. RN 5/13/1969 24 RUNNING BROOK RD. TRENTON NJ 08638 SUSPENSION 6/17/2004
NAPENAS, VICTOR T. 1/4/1947 14 SPRUCE LANE PISCATAWAY NJ 08854 DISQUALIFICATION 5/20/2012
NAPENAS, VICTOR T. 1/4/1947 14 SPRUCE LANE PISCATAWAY NJ 08854 DISQUALIFICATION 11/17/2011
NASH, JENNIFER RN/APN 11/30/1969 621 ASTER LANE RIVERVALE NJ 07675 DEBARMENT 7/3/2016
NASSAU PHARMACY 80 NASSAU STREET PRINCETON NJ 08540 DISQUALIFICATION
NASSERY, MOHAMMAD MD 4/18/1952 1992763510 59 TREELINE DRIVE MARSTONS MILLS MA 02648 DISQUALIFICATION 11/9/2016
NATALE, JOSEPH 2/8/1962 216 NORTH AVENUE E, STE. 2 CRANFORD NJ 07016 SUSPENSION 1/24/2014
NATHAN, MICHAEL MD 11/3/1949 1578593422 1 PROSPECT LANE OKATIE SC 29909 DEBARMENT 8/1/2017
NATIONAL SPINE MEDICAL
CENTER
2103 GOLDEN POND DRIVE KINGWOOD TX 77345 SUSPENSION 4/20/2005
NATOVICH, BORIS 2/25/1947 996 PINE TERRACE FRANKLIN LAKES NJ 07417 SUSPENSION 9/18/2003
NATOVICH, LEV 5/28/1968 996 PINE TERRACE FRANKLIN LAKES NJ 07417 SUSPENSION 9/18/2003
NAVAZIO, DAVID 11/22/1960 1368 BRENTWOOD RD. YARDLEY PA 19067 SUSPENSION 6/7/2000 1/5/2018
NAYLOR, KIM M. PHARM
TECH
9/15/1958 1504 TAMIAMI RD. FORKED RIVER NJ 08731 DEBARMENT 9/19/2011
NAZARIO, JULISSA CHHA 6/6/1992 210 ROSEVILLE AVENUE, APT.
C1
NEWARK NJ 07107 DISQUALIFICATION 2/20/2017
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
91
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
NEALS, SHERRY CHHA 12/19/1974 63 DALES AVENUE, APT. 1124 JERSEY CITY NJ 07306 SUSPENSION 9/20/2001
NEGRI, MARY JEAN RN/DC 11/21/1956 1063594836 514 LAFAYETTE RD., SUITE F SPARTA NJ 07871 DISQUALIFICATION 5/20/2015
NEGRON, JOANNA CHHA 7/24/1982 1343 LANDSDOWNE AVENUE CAMDEN NJ 08104 DISQUALIFICATION 5/2/2017
NELSON, SIDNEY MD 4517 BERGENLINE AVENUE UNION CITY NJ 07087 DEBARMENT 9/13/1999
NESSMAN, LAWRENCE DO 8/3/1931 143 GREENRALE AVENUE WAYNE NJ 07470 DISQUALIFICATION 6/24/1997
NEWBY, YVONNE CHHA 11/20/1966 38 WINANS STREET, APT. 3 EAST ORANGE NJ 07018 DISQUALIFICATION 8/29/2017
NEWMAN, ALEXANDER PHD 11/8/1947 372 N. WOODLAND STREET ENGLEWOOD NJ 07631 DEBARMENT 3/10/1999
NEWMAN, MICHAEL J. DMD 11/22/1954 192 GABRIEL TERRACE SOUTH AMBOY NJ 08879 DISQUALIFICATION 7/18/2001
NEWMARK, MALINDA RN 2/7/1969 38 STONY HILL RD., APT. 101 MONROE
TOWNSHIP
NJ 08831 SUSPENSION 5/19/2005
NEWMARK, THOMAS PSYCH 12/8/1944 1740380997 2250 CHAPEL AVENUE CHERRY HILL NJ 08002 DISQUALIFICATION 12/19/2016 PERMANENT
NEWMARK, THOMAS PSYCH 12/8/1944 1740380997 4700 CITY AVENUE, APT.
11307
PHILADELPHIA PA 19131 DISQUALIFICATION 4/17/2017 PERMANENT
NEWSOME, DORITA DDS 1/22/1956 1306063235 163 CHAPEL STREET ORANGE NJ 07050 DISQUALIFICATION 1/23/2009
NEWTON, ANDREW PSYCH 12/18/1961 1154349330 129 EAST 5TH STREET MOUNT CARAMEL PA 17851 DISQUALIFICATION 11/20/2015
NGOAJIA, MARK 7/23/1987 403 WILLOW POINT DRIVE JACKSON NJ 08724 DEBARMENT 12/16/2015
NGUYEN, TONY MD 10/7/1979 1083872675 10294 GREENSPIRE DRIVE OAKTON VA 22124 DISQUALIFICATION 9/28/2017
NIAZ, ASIM 7/11/1960 PO BOX 420 FAIRTON NJ 08320 SUSPENSION 8/19/2010
NICHOLSON, BEVERLY CNA 6/3/1947 139 HOLLYWOOD AVENUE EAST ORANGE NJ 07108 DISQUALIFICATION 1/13/2006
NICOLL, DAVID G. RN 3/10/1974 312 BOULEVARD MOUNTAIN LAKES NJ 07046 SUSPENSION 1/21/2015
NICOLL, SCOTT R. 9/20/1980 120 BUNKER HILL RD. WAYNE NJ 07470 SUSPENSION 1/21/2015
NICOSIA, BETTY LOU 6/23/1945 204 CIRCLE DRIVE STEUBENVILLE OH 43953 DISQUALIFICATION 12/29/2015
NIELSON, STEVEN C. DPM 10/22/1963 1538595772 845 DAWN AVENUE EPHRATA PA 17522 SUSPENSION 3/23/2009
NIGALAN, MANUEL MD 12/5/1943 1497809909 8 MIMI COURT NORTHFIELD NJ 08225 DISQUALIFICATION 10/14/2010
NII, ROBERT PA 12/25/1965 1124254107 34 MILL BROOK ROAD PISCATAWAY NJ 08854 DISQUALIFICATION 9/21/2016 PERMANENT
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
92
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
NINOS, DIANE E. 12/11/1975 569 E. 33RD STREET PATERSON NJ 07613 DISQUALIFICATION 3/28/2001
NISBETT, MELVIN CHHA 6/23/1990 205 LA CASCATA CLEMENTON NJ 08021 DISQUALIFICATION 2/8/2017
NISIVOCCIA, CHARLES DC 1/29/1967 260 MAIN STREET LITTLE FALLS NJ 07424 SUSPENSION 8/20/2006
NOBLES, MARITZA CHHA 9/2/1986 34 CENTER OAK AVENUE LAWNSIDE NJ 08045 DISQUALIFICATION 2/8/2017
NOBORE, ABIEYUWA CHHA 7/20/1986 776 SOUTH 13TH STREET NEWARK NJ 07108 DEBARMENT 2/20/2017
NONCENT, JENNIFER CHHA 6/2/1994 949 CARTERT AVENUE UNION NJ 07083 DISQUALIFICATION 2/8/2017
NONZIATO, CHARLES G. DO 2/26/1915 247 CENTER STREET TRENTON NJ 08611 DISQUALIFICATION 11/13/1991 DECEASED
NOOR, FARID A. MD 6/26/1956 1770751513 5 GITHERS LANE MEDFORD NJ 08055 SUSPENSION 4/12/2004
NOOR, FARID A. MD 6/26/1956 1770751513 350 A DELANCEY PLACE MOUNT LAUREL NJ 08054 DISQUALIFICATION 8/19/2008
NOOR, FARID A. MD 6/26/1956 1770751513 596 ANDERSON AVENUE CLIFFSIDE PARK NJ 07010 DEBARMENT 1/30/2015
NORDMAN, CRAIG J. 11/14/1978 4 ERNA PLACE WHIPPANY NJ 07981 SUSPENSION 1/21/2015
NORTH END FAMILY
MEDICAL CARE, INC.
1013079888 644 MT. PROSPECT AVENUE NEWARK NJ 07104 DISQUALIFICATION 7/20/2018
NORTHGATE COMMUNITY
PHARMACY
156 COUNTRY FARM ROAD MARLTON NJ 08053 DISQUALIFICATION 3/6/2006
NSIAH, KENNETH CHHA 6/25/1985 827 S. 17TH STREET, 2ND FL. NEWARK NJ 07108 DEBARMENT 7/14/2017
NTSHONA, NOKUZOLA S. MD 9/25/1951 113-15 34TH AVENUE, #4B CORONA NY 11368 DEBARMENT 1/12/2000
NURIK, BARUCH APT 9C PARKVIEW &
MADISON
LAURENCE HARBOR NJ 08879 DISQUALIFICATION 4/30/1995
NUSSBAUM, ABRAHAM MD 7/28/1950 1578598082 91 MONTGOMERY STREET RHINEBECK NY 12572 SUSPENSION 1/15/2001 11/12/2013
NWANKWO, FESTUS RPH 7/27/1959 154 BLOOMFIELD AVENUE NEWARK NJ 07104 DISQUALIFICATION 11/18/1998
NWANKWO, FESTUS RPH 7/27/1959 306 ARDSDALE TERRACE UNION NJ 07083 DISQUALIFICATION 2/18/1999
NWANKWO, RAPHAEL 7/4/1949 278 PARK AVENUE NEWARK NJ 07107 DISQUALIFICATION 5/19/1999
O'CALLAGHAN, TERESE RN 12/12/1958 5122 ORCHARD WAY PENNSAUKEN NJ 08109 SUSPENSION 10/20/2002
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
93
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
OCANSEY, DONNA RN 2/1/1962 7 WISINA COURT MEDFORD NJ 08055 DEBARMENT 4/22/2012
OCCEAN, NERLANDE CHHA 9/29/1974 811 DILL AVENUE LINDEN NJ 07036 DISQUALIFICATION 2/8/2017
O'CONNELL, MARK MD 2/19/1954 1669514253 18 CENTER STREET, REAR RUMSON NJ 07760 DEBARMENT 11/9/2015
ODOMS, TIFFANY E. 9/3/1983 926 TILGHMAN STREET CHESTER PA 19013 DISQUALIFICATION 11/18/2008
O'DONNELL, KATHERINE 1/23/1975 141 MAIN STREET METUCHEN NJ 08840 DISQUALIFICATION 9/30/2005
O'DONNELL, LISA RN 5/12/1976 845 BROADWAY BAYONNE NJ 07002 DISQUALIFICATION 6/15/2018
ODUNZEH, UCHE 10/28/1981 3565 LAUREL FORTE MEADE
RD., APT. 41
LAUREL MD 20724 DISQUALIFICATION 11/20/2015
OGANDO, ERNESTINA CHHA 7/27/1985 943 SHERIDAN AVENUE ELIZABETH NJ 07208 DEBARMENT 4/18/2017 6/28/2018
OGBEIDE-SIMMS, RACHEL CHHA 10/27/1965 15 MAPES PLACE NEWARK NJ 07112 DISQUALIFICATION 2/8/2017
OGORODOVA, GANNA CHHA 6/17/1983 310 BROMLEY PLACE EAST BRUNSWICK NJ 08816 DISQUALIFICATION 2/20/2017
OGUNTUASE, EBENEZER PHY THER 10/16/1959 10 DOCKSIDE DRIVE EGG HARBOR NJ 08234 DISQUALIFICATION 6/20/2009
O'HERN, DANIEL MD 3/8/1950 1144369554 18 FLEETWOOD DRIVE GOSHEN NY 10924 DISQUALIFICATION 3/3/2017 PERMANENT
OJAH CORPORATION 42/44 SUSSEX AVENUE EAST ORANGE NJ SUSPENSION 3/22/2006
OJIKYTU, SIMBIAT T. CHHA 5/5/1987 51 LEXINGTON BLVD BARNEGAT NJ 08005 DISQUALIFICATION 5/2/2014
OJO, RICHARD O. 9/10/1986 346 FIELDCREST AVENUE NEW EGYPT NJ 08533 DEBARMENT 2/24/2009
OKANTA, MARGARET CHHA 11/11/1941 1854B MANOR DRIVE UNION NJ 07083 DEBARMENT 7/30/2005
OKOYE, GODWIN S. RPH 1/1/1962 289 GEORGE STREET NEW BRUNSWICK NJ 08901 SUSPENSION 1/12/2001
OKOYE, PATRICK C. RPH 5/2/1970 289 GEORGE STREET NEW BRUNSWICK NJ 08901 SUSPENSION 1/12/2001
OKREM, JANINE RN 10/21/1970 1112 HARKER AVENUE WEST DEPTFORD NJ 08096 DISQUALIFICATION 7/12/2018
OLDE MEDFORD
PHARMACY
1619148632 639 STOKES ROAD, SUITE 101 MEDFORD NJ 08055 DISQUALIFICATION 4/13/2018
OLIVEIRA JR., MARIO OD 4/8/1963 170 EAST KINNEY STREET NEWARK NJ 07105 DEBARMENT 4/28/2005
OLIVER, JAMES DDS 3/1/1946 1134314594 167 MAIN STREET METUCHEN NJ 08840 DEBARMENT 8/13/1999
OLIVERA, PABLO R. DPM 4/28/1958 2 CEDAR STREET NEWARK NJ 07102 SUSPENSION 9/20/2001
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
94
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
OLIVERA, SMIRNA LPN 8/15/1958 33 REMSEN AVENUE NEW BRUNSWICK NJ 08901 SUSPENSION 10/20/2002
OLIVEROS, APRIL LPN 4/2/1985 233 SMOKERISE LANE TOMS RIVER NJ 08755 DISQUALIFICATION 6/5/2017
OLIYNYK, OKSANA CHHA 5/9/1970 591 MARLBORO ROAD OLD BRIDGE NJ 08857 DEBARMENT 2/20/2017
OMAR, HATIEM 4/20/1966 1116 ANNE STREET ELIZABETH NJ 07201 DISQUALIFICATION 11/10/1999
OMAR, MUGAHID O. 3/29/1967 7-11 TONNELLE AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 3/14/1998
OMAR, MUGAHID O. 3/29/1967 7-11 TONNELLE AVENUE-2MN JERSEY CITY NJ 07306 DISQUALIFICATION 4/10/1997
O'NEILL - RYAN, LISA ANNE COUNSEL
OR
8/20/1961 415 LYNDALE STREET PHILLIPSBURG NJ 08865 DISQUALIFICATION 8/17/2008
O'NEILL - RYAN, LISA ANNE COUNSEL
OR
8/20/1961 415 LYNDALE STREET PHILLIPSBURG NJ 08865 SUSPENSION 5/9/2008
ONYEKAHA, EBERE RPH 11/15/1958 13 HIGHLAND AVENUE MAPLEWOOD NJ 07040 DISQUALIFICATION 12/1/1998
ONYENSO, CHIKE MD 9/18/1958 1578605812 552 MAIN STREET CHATHAM NJ 07928 SUSPENSION 2/15/2012
ONYENSO, CHIKE MD 9/18/1958 1578605812 18 EDINBURGH DRIVE RANDOLPH NJ 07869 DISQUALIFICATION 3/19/2015
OQUENDO, BASHIRAH CHHA 11/6/1986 87 MANNING AVENUE PLAINFIELD NJ 07060 DISQUALIFICATION 2/8/2017
ORANGE COMMUNITY MRI 345 HENRY STREET ORANGE NJ 07055 SUSPENSION 3/16/2012
O'REILLY, RAYMOND B 2/20/1949 188 ALEXANDRIA DR HACKETTSTOWN NJ 07840 DISQUALIFICATION 6/1/1993
OREM, SUSAN RN 5/18/1960 140 VALERIE DRIVE #488 MANVILLE NJ 08835 SUSPENSION 9/20/2006
ORIA, CONRAD RN 7/26/1976 525 BLOOMFIELD AVENUE CALDWELL NJ 07006 DEBARMENT 6/5/2017
ORT II, CHARLES C. PA 10/4/1957 PO BOX 481 HACKETTSTOWN NJ 07840 DISQUALIFICATION 11/18/2004
ORTEGA, ANA CHHA 11/16/1967 14 PALM STREET MONMOUTH
JUNCTION
NJ 08852 DISQUALIFICATION 2/8/2017
ORTEGA, VICTOR 10/14/1967 GUAYNBO- PO BOX 2147 SAN JUAN PR 00922 SUSPENSION 7/18/2002
ORTELL, CARL RPH 7/30/1937 221 TINDERBOX LANE MARLTON NJ 08053 DISQUALIFICATION 12/5/1983
OSAIGBOVO, ASHLEY CHHA 3/25/1994 130 PAMPHYLIA AVENUE,
APT. #70
BRIDGETON NJ 08302 DISQUALIFICATION 10/19/2017
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
95
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
OSEI, CALVIN RPH 8/24/1977 1497931794 2 SYSLO COURT SAYREVILLE NJ 08872 DISQUALIFICATION 9/4/2012 6/12/2018
OSEI, FRANCIS LPN 4/9/1966 50 N. EVERGREEN ROAD, APT.
170M
EDISON NJ 08837 DISQUALIFICATION 8/24/2017
OSEI, PASCAL RPH 11/11/1958 9 SOUTH GROSSER PLACE SOMERSET NJ 08873 DEBARMENT 7/17/2009 7/17/2014
OSIFO, BAHEEJAH CHHA 9/11/1979 530 PARK AVENUE ORANGE NJ 07050 DISQUALIFICATION 2/8/2017
OSMANOFF, GARY DDS 5/13/1962 1710188073 NETTER COURT MARLBORO NJ 07746 DISQUALIFICATION 6/23/2008
OSMANOFF, GARY DDS 5/13/1962 1710188073 317 MARINE AVENUE BROOKLYN NY 11209 SUSPENSION 12/17/2008
OSTERGAARD, PAUL MD 3/15/1941 1962504753 230 WEST PARKWAY POMPTON PLAINS NJ 07444 DEBARMENT 2/21/2014
OSTERGAARD, PAUL MD 3/15/1941 1962504753 230 WEST PARKWAY POMPTON PLAINS NJ 07444 DISQUALIFICATION 2/11/2016
OSTROSKIE, JOAN LPN 4/3/1953 424 FLORENCE STREET NEW MILFORD NJ 07646 SUSPENSION 1/19/2003
OSTWALD, ALICE LPN 2/7/1962 11 RAILROAD LANE WHITEHOUSE NJ 08889 SUSPENSION 9/20/2006
OSUJI, PAUL 12/7/1963 FCI FORT DIX, PO BOX 2000 FORT DIX NJ 08640 SUSPENSION 8/20/2009
OTI, CHUCK B. 9/1/1973 676 PARK AVENUE, BLDG. 14B EAST ORANGE NJ 07017 DISQUALIFICATION 1/31/2000
OTISMED CORPORATION 1600 HARBOR BAY PKWY.,
SUITE 200
ALAMEDA CA 94502 DISQUALIFICATION 4/27/2015
OTOO, LOVE CHHA 5/21/1957 555 ELIZABETH AVENUE NEWARK NJ 07112 DISQUALIFICATION 2/8/2017
OTTENSTEIN, ALAN MD 6/1/1956 3100 PRINCETON PIKE LAWRENCEVILLE NJ 08648 SUSPENSION 3/1/2009
OTTENSTEIN, ALAN MD 6/1/1956 173 MOUNT EYRE RD. WASHINGTON
CROSSING
PA 18977 SUSPENSION 5/19/2005
OWUSU, NICHOLAS CHHA 2/3/1955 6063 HAMPSTEAD DRIVE W COLUMBUS OH 43229 DISQUALIFICATION 2/27/2017 PERMANENT
OWUSU,-ANSAH, GRACE CHHA 9/21/1963 97-22 57TH AVENUE CORONA NY 11368 DISQUALIFICATION 5/17/2018
OXFORD DIABETIC SUPPLY,
INC.
1700016045 53 FRONTAGE ROAD, SUITE
100
HAMPTON NJ 08827 DISQUALIFICATION 12/8/2016
OXMAN, REED S. MD 3/8/1959 1649575473 226 W. RITTENHOUSE
SQUARE
PHILADELPHIA PA 19103 SUSPENSION 3/16/2012
OYENUSI, ADEBOWALE RPH 4/4/1956 90 WASHINGTON STREET EAST ORANGE NJ 07017 DEBARMENT 10/14/2000
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
96
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
OZERY, TZIPORA AKA
MONICA MOORE
2/1/1969 27 FIRETOWER ROAD BUDD LAKE NJ 07828 DEBARMENT 9/15/2017
PABBATHI, RAMMOHAN 11/25/1946 3 AMY COURT HOWELL NJ 07731 DEBARMENT 7/8/2005
PACHECO, ALVARO R. 59 EDGEHILL COURT WEST ORANGE NJ 07052 DISQUALIFICATION 6/1/1993
PACHECO, MICHAEL PHARM
TECH
9/2/1975 84 LAFAYETTE AVENUE PASSAIC NJ 07055 DEBARMENT 7/18/2003
PADUANO JR., FRANCIS P. RPH 10/15/1947 2020 BALMORAL AVENUE UNION NJ 07735 DISQUALIFICATION 9/16/1986
PADVA-GERMAN, ANNA DDS 8/21/1962 1043382039 446 DUBLIN PLAZA SECAUCUS NJ 07094 DEBARMENT 12/14/2009
PADVA-GERMAN, ANNA DDS 8/21/1962 1043382039 446 DUNLIN PLAZA, 446H SECAUCUS NJ 07094 DEBARMENT 10/15/2014
PAGANO, NICOLE RN 4/5/1973 531 PARKWAY AVENUE TRENTON NJ 08618 DISQUALIFICATION 5/20/2009
PAGONZAGA, GLORIA CHHA 12/20/1950 313 OLD BERGEN ROAD, APT.
2
JERSEY CITY NJ 07305 DISQUALIFICATION 2/20/2017
PAKETT, NEIL DMD 7/18/1950 1184934663 777 WEST GERMANTOWN
PIKE, APT. 530
PLYMOUTH
MEETING
PA 19462 DISQUALIFICATION 11/20/2015
PALMER, THOMAS #14570-
003
RN 5/31/1975 1912200932 FPC PENSACOLA, PO BOX
3949
PENSACOLA FL 32516 DISQUALIFICATION 9/29/2017
PAMIDIMUKKALA, VIJAY RPH 8/14/1951 1598087272 3 PENROSE COURT EDISON NJ 08820 SUSPENSION 9/13/1999
PANCELLI, JOHN M. MD 11/26/1961 WEST JERSEY HOSPITAL CAMDEN NJ 08104 DISQUALIFICATION 12/1/1998 DECEASED
PANGANIBAN, ARMANDO RN 1/5/1953 CYPRESS RD. TOMS RIVER NJ 08753 DISQUALIFICATION 8/11/2007
PANICHELLA, ANTHONY G. COUNSEL
OR
1/16/1955 739 S. WHITE HORSE PIKE AUDUBON NJ 08106 SUSPENSION 7/20/2006
PANITCH, EDWIN RPH 1/1/1931 8 POINT OF WOODS DR NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 6/1/1993
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
97
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
PANJWANI, HARRY K. MD 6/1/1927 EAST 42 FAIRVIEW TERRACE PARAMUS NJ 07652 DEBARMENT 5/24/1999
PANOS, SPYROS MD 9/30/1968 1497753149 #69361-054 USP CANAAN, PO
BOX 300
WAYMART PA 18472 DISQUALIFICATION 11/20/2015
PAPPALARDO, PETER S. MD 6/27/1937 4 SOUTH AIRMONT RD SUFFERN NY 10901 DISQUALIFICATION 6/1/1993
PARADISO, NINO RPH 8/20/1943 57 POPLAR DRIVE MORRIS PLAINS NJ 07950 DISQUALIFICATION 9/9/2016
PARASHOS, LINDA RN 4/7/1963 514 9TH AVENUE LINDENWOLD NJ 08021 SUSPENSION 5/20/2001
PARCHMENT, ALFRED MD 12/31/1962 1073587242 1140 BURT TAVERN ROAD BRICK NJ 08724 DISQUALIFICATION 10/25/2016
PAREKH, CHANDRAKANT DDS 6/30/1948 1144386178 6529 GERMANTOWN AVENUE PHILADELPHIA PA 19119 DISQUALIFICATION 11/20/2015
PARIDA, SAROJ K. MD 10/21/1959 1013975549 USP LEWIS-PO BOX 1000 LEWISBURG PA 17837 DISQUALIFICATION 8/20/2013
PARIKH, BIPIN J. MD 8/4/1945 1962555193 224 LAFAYETTE STREET WILLISTON PARK NY 11596 SUSPENSION 11/20/2010
PARIKH, BIPIN J. MD 8/4/1945 1962555193 224 SOUTH LAFAYETTE
STREET
WILLISTON PARK NY 11596 SUSPENSION 7/9/2008
PARIKH, MANUPRASAD RPH 6/23/1941 209 STOKES FARM RD. FRANKLIN LAKES NJ 07417 SUSPENSION 7/20/2004 9/5/2017
PARK MEDICAL
LABORATORY
298 CLAIRMONT AVENUE MONTCLAIR NJ 07042 DISQUALIFICATION 8/20/1976
PARKOFF, MICHAEL A. DMD 9/3/1948 68 MAPLEWOOD BLVD SUFFERIN NY 10901 DISQUALIFICATION 8/7/1984
PASCUCCI, LAVERNE CHHA 7/5/1946 160 JAMES STREET TOMS RIVER NJ 08753 DISQUALIFICATION 2/8/2017
PATANKAR, SANJIV MD 5/9/1958 1255429361 61 HARDWICK DRIVE KENDALL PARK NJ 08824 DEBARMENT 12/19/2017
PATEL, ARUNA S. MD 11/1/1944 1770568610 725 NORTH BROAD STREET ELIZABETH NJ 07208 DISQUALIFICATION 6/26/2008
PATEL, ASHOKKUMAR R. 5/14/1961 11 YARDLEY STREET EDISON NJ 08820 DISQUALIFICATION 8/10/2007
PATEL, BELA RPH 8/15/1979 1701 COTTMAN AVENUE PHILADELPHIA PA 19111 DISQUALIFICATION 4/9/2015
PATEL, BHARAT KUMAR RPH 7/15/1966 1962729731 140 RIVERSIDE BLVD. NEW YORK NY 10069 DISQUALIFICATION 4/20/2014
PATEL, CHANDRAKANT 40 GALESI DRIVE WAYNE NJ 07470 SUSPENSION 3/28/2000 12/12/2007
PATEL, CHIRAG J. 9/22/1975 16 SNEIDER RD. WARREN NJ 07059 SUSPENSION 4/2/2012
PATEL, CHIRAG J. 9/22/1975 16 SNEIDER RD. WARREN NJ 07059 DISQUALIFICATION 4/20/2015
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
98
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
PATEL, DINESH R. MD 3/6/1954 1285702829 3 BRIGHTON COURT LIVINGSTON NJ 07039 SUSPENSION 3/17/2012
PATEL, DINESH R. MD 3/6/1954 1285702829 835 CLINTON AVENUE NEWARK NJ 07108 DISQUALIFICATION 2/20/2014
PATEL, DINESH R. MD 3/6/1954 1285702829 3 BRIGHTON COURT LIVINGSTON NJ 07039 DISQUALIFICATION 9/27/2017
PATEL, MAHESH I. MD 10/26/1949 1942202841 3 PINE VALLEY WAY FLORHAM NJ 07932 DISQUALIFICATION 1/26/2015
PATEL, MEHMOOD M. MD 5/25/1945 1225074859 201 MIDDLETON RD. LAFAYETTE LA 70503 DISQUALIFICATION 2/26/2010
PATEL, PARESH R. DMD 6/7/1965 1134106511 295 MAIN STREET METUCHEN NJ 08840 DISQUALIFICATION 5/22/2014
PATEL, PARESHCHANDRA
C.
MD 8/24/1960 1306073200 8 NOTTINGHAM ROAD EDISON NJ 08820 DEBARMENT 11/21/2016
PATEL, PRAVIN, K. MD 5/17/1957 904 #35 IVY RIDGE RD SYRACUSE NY 13210 SUSPENSION 12/19/2002
PATEL, RAMBEN
DAHYABHAI
LPN 7/31/1953 505 WEST MINISTER BLVD. PARLIN NJ 08859 SUSPENSION 8/20/2000
PATEL, RAMESH SHANKER
BHAI
RN 8/15/1959 PO BOX 5564 OLD BRIDGE NJ 08857 SUSPENSION 6/20/2001
PATEL, RITA RPH 6/2/1965 4 HAUSER LANE MATAWAN NJ 07747 SUSPENSION 3/10/2016 2/17/2017
PATEL, RITA RPH 6/2/1965 4 HAUSER LANE MATAWAN NJ 07747 DEBARMENT 3/20/2017 10/19/2017
PATEL, RITA RPH 6/2/1965 4 HAUSER LANE MATAWAN NJ 07747 DISQUALIFICATION 10/19/2017
PATEL, SANJAY I. RPH 6/4/1965 1316335961 63 HEATHERDELL RD. ARDSLEY NY 10502 DEBARMENT 4/26/2016
PATEL, SANJAY I. RPH 6/4/1965 1316335961 63 HEATHERDELL RD. ARDSLEY NY 10502 SUSPENSION 4/20/2006
PATEL, SHIRJAY CHHA 6/12/1993 703 NEW DOVER ROAD EDISON NJ 08820 DISQUALIFICATION 2/20/2017
PATEL, VIJAY 1/1/1957 65 W. LINCOLN AVENUE ROCKAWAY NJ 07866 DISQUALIFICATION 11/20/2017
PATEL, VITTHAL I. RPH 5/31/1954 ST. GEORGE AVENUE, APT.
141
AVENEL NJ 07001 SUSPENSION 9/20/2004
PATHARKAR, MANOJ MD 4/13/1971 1598808339 16 LINDA COURT LAURENCE HARBOR NJ 08879 DISQUALIFICATION 12/19/2016 PERMANENT
PATIN, YURY MD 9/8/1956 1548325400 45 BEVERLY RD. SUMMIT NJ 07901 DISQUALIFICATION 2/26/2009
PATTERSON JR., ARTHUR DC 5/2/1958 1164628822 8 FELLOWSWOOD WAY HOLMDEL NJ 07733 DEBARMENT 7/18/2014
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
99
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
PATTERSON, KELEE RN 3/3/1986 577 EAST ROAD BELFORD NJ 07718 DISQUALIFICATION 6/28/2017
PAUL, DAVID M. MD 5/6/1948 1124355250 434 RAHWAY AVENUE WOODBRIDGE NJ 07095 DEBARMENT 3/22/2002
PEACOCK, DENISE RN 9/8/1978 9331 GLENLOCH STREET PHILADELPHIA PA 19114 DISQUALIFICATION 11/20/2015
PEARSON, KATIE LPN 6/19/1981 229 SNOOKS HILL RD. LEWISTOWN PA 17044 DISQUALIFICATION 11/20/2015
PEART, HAROLD G. LCSW 8/31/1932 3 HARRISON PARK LANE BURLINGTON NJ 08016 SUSPENSION 3/17/2000
PEART, HAROLD G. LCSW 8/31/1932 415 KEIM BOULEVARD BURLINGTON NJ 08016 SUSPENSION 8/20/1999
PECK, MARVIN RPH 5/18/1937 335 GEORGE STREET NEW BRUNSWICK NJ 08901 DISQUALIFICATION 6/1/1993
PELLEGRINO, TAMMY RN 8/20/1964 2423 SHADY LANE, APT. P ATCO NJ 08004 SUSPENSION 2/20/2003
PELLICANO, PAUL J. MD 6/25/1939 1316282783 120 MILLBURN AVENUE, STE.
M1
MILLBURN NJ 07041 DISQUALIFICATION 12/1/1998
PEMBERTON, COLIN MD 5/6/1975 1891935557 500 ORANGE STREET NEWARK NJ 07107 DISQUALIFICATION 8/28/2017 4/26/2018
PENA, CARMEN F. DDS 8/29/1961 1871750166 800 76TH ST., 2ND FLOOR NORTH BERGEN NJ 07047 SUSPENSION 9/20/2000 9/15/2015
PENALES, AMANDO D. 7/30/1973 BAYSIDE PRISON, PO BOX F-1 LEESBURG NJ 08327 DISQUALIFICATION 5/9/2014
PENALVER, FAITH RN 10/5/1943 4 MAPLE COURT ROOSEVELT NJ 08555 SUSPENSION 5/19/2005
PENFIELD, JOHN DO 9/18/1967 1528078839 25 POCONO RD. DENVILLE NJ 07834 DEBARMENT 3/6/2014 3/2/2018
PENFIELD, JOHN DO 9/18/1967 1528078839 308 MURRAY HILL RD. VESTAL NY 13850 DISQUALIFICATION 11/20/2015 3/2/2018
PENICO, PETER MD 10/25/1915 300 MAIN STREET MILLVILLE NJ 08332 DISQUALIFICATION 8/24/1978 DECEASED
PEOPLE CHOICE HOME
CARE
1851416069 430 MORRIS AVENUE ELIZABETH NJ 07208 DISQUALIFICATION 5/24/2017
PERERA, SANTUSHT MD 9/29/1961 1942311147 7 GREENHILL ROAD KINNELON NJ 07405 DISQUALIFICATION 12/22/2016 PERMANENT
PEREZ, JORGE MD 9/24/1944 213 14TH STREET PALISADES PARK NJ 07650 SUSPENSION 3/18/2004
PEREZ, JUANA CHHA 4/18/1963 510 25TH STREET UNION CITY NJ 07087 DISQUALIFICATION 2/20/2017
PERLMAN, BERNARD MD 9/8/1952 1477579456 42 OAKMONT RD. YARMOUTH PORT MA 02675 DEBARMENT 1/3/2000 9/12/2017
PERRIN, DOUGLAS M. CHHA 4/18/1968 1801 LAURAL RD. LINDENWOLD NJ 08021 SUSPENSION 5/20/2002
PERRY, ELSWETTA CHHA 9/20/1955 291 NORTH PARK STREET, 1ST
FLOOR
EAST ORANGE NJ 07017 DISQUALIFICATION 3/12/2018
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
100
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
PESCIOTTA, BARBARA ANN RPH 10/9/1966 992 VAUGHN AVENUE TOMS RIVER NJ 08753 DEBARMENT 5/18/2006
PESCIOTTA, ROY THOMAS RPH 5/29/1967 992 VAUGHN AVENUE TOMS RIVER NJ 08753 DEBARMENT 5/18/2006
PETERSEN, PETHINA CHHA 1/23/1955 289 MLK DRIVE JERSEY CITY NJ 07305 SUSPENSION 5/20/2004
PETIT, MADELINE CNA 2/13/1951 228 70TH STREET, 2ND FL. GUTTENBERG NJ 07093 DISQUALIFICATION 7/7/2008
PETRUCELLI, SALVATORE MD 2/22/1950 201 LYONS AVENUE NEWARK NJ 07112 DEBARMENT 2/2/2000
PETTERSEN, LINDA A. RN 5/8/1955 700 PARK BLVD. CHERRY HILL NJ 08002 SUSPENSION 10/20/2002
PFAUTZ, JOANNA LPN 10/17/1973 1595 BREAKERS DRIVE, #A MANAHAWKIN NJ 08050 DISQUALIFICATION 5/2/2018
PHARES, ALYSSA RN 7/25/1971 21 WOODLAND WAY DAYTON NJ 08810 SUSPENSION 9/19/2002
PHILEMON, MENAHEM CHHA 1/1/1980 265 KING VILLAGE BUDD LAKE NJ 07869 DISQUALIFICATION 5/18/2018
PHILIPPE, ADELINE CHHA 1/30/1967 61 CLEVELAND STREET, APT.
2E
ORANGE NJ 07050 DISQUALIFICATION 3/12/2018
PHILIPPE, IRLANDE RN 4/16/1966 29 ELM STREET WEST ORANGE NJ 07052 DISQUALIFICATION 7/22/2017
PHILLIPS, RONALD DO 12/17/1944 718 HAVEN PLACE LINDEN NJ 07026 DEBARMENT 1/8/1999
PHIPPS JR., ERNEST MD 11/6/1963 130 FORD RD. HOWELL NJ 07731 SUSPENSION 5/20/2004
PIACENTILE, JOSEPH MD 4/3/1956 1265607410 578 BIG OAK RD. YARDLEY PA 19067 DISQUALIFICATION 12/17/1995
PIAZZA, GARY G. DO 3/28/1952 7 CARRIAGE PLACE EDISON NJ 08820 DISQUALIFICATION 10/20/1998
PICARIELLO, JOSEPH 12/18/1954 1202 FOX CHASE LANE WHIPPANY NJ 08981 DISQUALIFICATION 6/9/2000 6/1/2016
PIERCE, JACQUELINE CHHA 4/2/1986 1066 NORTH 28TH STREET CAMDEN NJ 08105 DEBARMENT 7/14/2017
PIERCE, LESLIE CHHA 3/31/1968 511 1ST AVENUE, APT. #3-W ASBURY PARK NJ 07712 DEBARMENT 3/6/2018
PIERRE, OTILIEN CHHA 2/10/1972 454 SOUTH OLDEN AVENUE TRENTON NJ 08609 DISQUALIFICATION 2/20/2017
PIERSON, GEORGE T. DO 9/1/1929 5 RAINBOW TRAIL SPARTA NJ 07871 DISQUALIFICATION 4/2/1988 DECEASED
PIMPONG, SWANZYBELLA LPN/RN/
CHHA
9/3/1975 14 3RD STREET, FLOOR 1 NEWARK NJ 07107 DISQUALIFICATION 3/3/2017
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
101
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
PINEDA, FRANCESCA RN 3/9/1950 151 TRAILS END NEW CITY NY 10956 SUSPENSION 10/18/2001
PINKERTON, MARIAN LPN 6/20/1957 410 THOMAS AVENUE RIVERTON NJ 08077 SUSPENSION 9/19/2003
PINNAMARAJU, VENKATA RPH 5/23/1977 5234 FOX RIDGE ROAD ROANOKE VA 24018 DISQUALIFICATION 5/24/2017
PIOTROWSKI, DENISE CHHA 4/24/1971 100 EAST MAIN STREET MARLTON NJ 08053 DEBARMENT 7/31/2017
PIRLAMARLA, JYOTI MD 12/30/1950 1952349425 77 JACKSON MILLS ROAD FREEHOLD NJ 07728 DISQUALIFICATION 9/21/2016
PIRMISASHVILI, TEA CHHA 8/16/1976 43 LINDEN STREET FORDS NJ 08863 DISQUALIFICATION 2/20/2017
PIROVOLOS, NICHOLAS RPH 1/10/1930 30 DWIGHT DRIVE WEST DEAL NJ 07712 DISQUALIFICATION 9/16/2000
PIROVOLOS, NICHOLAS RPH 1/10/1930 30 DWIGHT DRIVE OCEAN NJ 07712 SUSPENSION 10/20/2002
PISANI, LOUIS RPH 7/19/1951 1215250709 2 E. FRANKLIN COURT GARDEN CITY NY 11530 SUSPENSION 10/19/2000
PISANI, LOUIS RPH 7/19/1951 1215250709 PO BOX 737513 ELMHURST NY 11373 DISQUALIFICATION 6/3/2016
PIUCK, CHARLOTTE L. MD 7/22/1922 593 RAMAPO VALLEY RD. OAKLAND NJ 07436 DISQUALIFICATION 10/25/2001
PIZZARELLI, ANGELA D. 6/19/1981 1111 BOND STREET ASBURY PARK NJ 07712 DISQUALIFICATION 7/18/2001
PLANT, CHINIA 1/20/1980 2013 LOGAN STREET HARRISBURG PA 17102 DISQUALIFICATION 11/20/2015
PLINIO, STEVEN DC 5/20/1966 655 AMBOY AVENUE WOODBRIDGE NJ 07095 DEBARMENT 9/30/1999
PLOTNIK, PYOTR MD 2/15/1944 1407019813 276 COLERIDGE STREET BROOKLYN NY 11235 DEBARMENT 5/23/2000
PLOTTS, LISA (FROSCH) RN 4/15/1976 111 BEECHWOOD AVENUE OAKLYN NJ 08107 SUSPENSION 10/18/2001
PLUCINSKI, PATRICIA LPN 8/11/1964 201 HAEGELE PLACE MOUNT ROYAL NJ 08061 SUSPENSION 12/20/2009
POET, ALBERT MD 6/10/1949 1134270903 EAST BAY AVENUE MANAHAWKIN NJ 08050 DISQUALIFICATION 8/10/2007
POFF, SHIABON LPN 7/31/1979 48 CHESTNUT STREET WARETOWN NJ 08758 DISQUALIFICATION 8/22/2017
POGGIOLI, STEPHAN 5/11/1963 431 ACADEMY TERRACE LINDEN NJ 07036 SUSPENSION 6/18/2004
POH-EIKOM, VICKI 9/8/1953 619A BILLINGS AVE. PAULSBORO NJ 08062 DEBARMENT 12/29/1999
POH-EIKOM, VICKI 9/8/1953 619A BILLINGS AVE. PAULSBORO NJ 08062 DEBARMENT 1/11/2000
POINTE O'WOODS
PHARMACY
999 US HIGHWAY ROUTE 9 HOWELL NJ 07731 DISQUALIFICATION 7/11/2000
POLANSKY, IRVING RPH 2/5/1926 260 MAIN ST KEANSBURG NJ 07734 DISQUALIFICATION 7/9/1985
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
102
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
POLISE, VINCENZO RPH 11/26/1973 33 HARRISON ROAD KINNELON NJ 07405 DEBARMENT 12/31/2015
POLISHUK, ANDRIJ 9/1/1953 649 PULHAM COURT #A MANCHESTER NJ 08759 SUSPENSION 3/8/2008
POLLACK, EARL T. DMD 12/16/1930 171 N. LANSDOWNE AVENUE LANSDOWNE PA 19050 DISQUALIFICATION 11/7/1986
POLLACK, JOSEPH DPM 11/23/1906 PO BOX 11401 YARDVILLE NJ 08628 DISQUALIFICATION 9/30/1982 9/30/1987
POLLEN, PHILIP C. MD 9/1/1954 1245341924 245 ROUTE 9 MORGANVILLE NJ 07751 DEBARMENT 10/28/2013
POOLE, JAMES RN 4/29/1977 1639367972 34 SOUTH 2ND STREET, APT. 5 DEQUESNE PA 15110 DISQUALIFICATION 11/20/2015
POOLE, KENDRA CHHA 9/6/1985 222 COOLIDGE AVENUE TRENTON NJ 08618 DISQUALIFICATION 1/23/2018
POPICK, ALAN DO 1/23/1948 1194789214 1532 CREEKSIDE ROAD WHITEHALL PA 18052 DISQUALIFICATION 2/11/2016
POPKU, BISMARK CHHA 6/14/1968 2468 ANGLER ROAD COLUMBUS OH 43224 DISQUALIFICATION 4/6/2018
POROGER, EMMA DO 5/27/1955 1669572368 59 LINWOOD ROAD STATEN ISLAND NY 10308 DISQUALIFICATION 5/12/2016
POSNER, ROBERT S. DDS 6/21/1957 1740518992 53 WESTFIELD AVENUE CLARK NJ 07066 DISQUALIFICATION 6/23/1999
POTACCO, PHILIP DC 5/6/1952 54 CHURCH STREET SOUTH ORANGE NJ 07079 SUSPENSION 2/20/2003
POTTER, DIANE LPN 4/7/1968 215 FAIRFIELD LANE KING WILLIAM VA 23086 DISQUALIFICATION 5/20/2009
POWELL, WILLIE MFT 2130 MILLBURN AVENUE MAPLEWOOD NJ 07040 DISQUALIFICATION 9/12/2016 PERMANENT
PRAVETZ, MICHAEL MD 3/20/1949 531 GATES STREET PHILADELPHIA PA 19128 DEBARMENT 3/5/2001
PRECISE MEDICAL LAB., INC 1265 PATERSON PLANK ROAD SECAUCUS NJ 07094
DISQUALIFICATION
12/1/1998
PRENSKY, JOSHUA DMD 6/19/1976 1578761961 28-10 HIGH STREET FAIRLAWN NJ 07410 DISQUALIFICATION 7/17/2009
PRENSKY, JOSHUA DMD 6/19/1976 1578761961 2810 HIGH ST. BERGEN NJ 07410 DISQUALIFICATION 5/29/2013
PRESILLA, ALEJANDRO MD 6/11/1948 1902835747 15 FULTON STREET WEEHAWKEN NJ 07086 DEBARMENT 4/30/2010 4/30/2013
PRESS, STUART M. MD 3/29/1952 1525 E. PUTNAM AVENUE
#206
OLD GREENWICH CT 06870 DISQUALIFICATION 8/1/2009
PRINTZ, BRUCE I. DO 11/28/1952 400 GILL LANE ISELIN NJ 08830 SUSPENSION 6/6/2004
PRITCHARD, JOSEPH 11/24/1955 69 TALLWOOD DRIVE MEDFORD NJ 08055 SUSPENSION 5/9/2002 12/10/2014
PROSKUROVSKY, BORIS 3/27/1947 218 HALSEY STREET NEWARK NJ 07102 DISQUALIFICATION 8/4/1997
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
103
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
PROSKUROVSKY, BORIS 3/27/1947 218 HALSEY STREET NEWARK NJ 07102 SUSPENSION 8/25/1998
PROTAS, OLEG CHHA 9/6/1987 407 LIBERTY LANE MARLTON NJ 08053 DISQUALIFICATION 7/26/2017
PROVOST, LAURIE LPN 2/26/1960 10 BALTIMORE BLVD SEA GIRT NJ 08750 SUSPENSION 1/24/2014
PRZADOWSKA-KOKINDA,
ELIZABETH M.
RN 6/13/1978 1106 PARKSIDE AVENUE TRENTON NJ 08618 SUSPENSION 4/20/2005
PUCCI, BRIAN M. RPH 4/6/1958 14 RAND RD. PINE BROOK NJ 07058 SUSPENSION 9/20/2005 9/19/2014
PUENTES, ELENA CHHA 11/28/1960 374B HAMILTON STREET SOMERSET NJ 08873 SUSPENSION 5/14/2007
PUGLIESE, GIROLAMO MD 2/20/1922 103 MAIN STREET KEYPORT NJ 07735 SUSPENSION 2/22/1999 DECEASED
PULVIRENTI, FRANCESCA
M.
CHHA 4/21/1979 212 8TH STREET SURF CITY NJ 08008 SUSPENSION 9/29/2005
PURNESS, TIFFANY CHHA 8/11/1990 105 BLACKWOOD-
CLEMONTON ROAD #704
LINDENWOLD NJ 08021 DISQUALIFICATION 4/26/2018
QAYYUM, ABDUL RPH 12/2/1949 960 COUNTRY CLUB DRIVE TEANECK NJ 07666 SUSPENSION 4/27/2000
QUEST, BRITTANY CHHA 8/27/1989 379 SANFORD AVENUE NEWARK NJ 07106 DISQUALIFICATION 2/8/2017
QUICK SCRIPT PHARMACY 90 WASHINGTON STREET EAST ORANGE NJ 07017 SUSPENSION 9/22/2000
QUIJADA, CARLOS COUNSEL
OR
3/27/1980 106 SPRING VALLEY AVENUE,
#1
HACKENSACK NJ 07601 DISQUALIFICATION 12/20/2012
QUINN, JOHN, C. RN 1/19/1959 437 HARRISTOWN RD. GLEN ROCK NJ 07452 SUSPENSION 6/20/2006
QUINONES, ANEL 11/1/1960 48 GRAND STREET GARFIELD NJ 07026 DISQUALIFICATION 9/11/2001
QUINONES, ELIZABETH CHHA 5/17/1969 210 BOND STREET ELIZABETH NJ 07206 DISQUALIFICATION 2/8/2017
QURESHI, SHAMS MD 4/19/1950 1194743377 1084 MAIN AVENUE CLIFTON NJ 07011 DEBARMENT 1/27/2012
R & M CORPORATION 156 COUNTRY FARM ROAD MARLTON NJ 08053 DISQUALIFICATION
RAAB, TERRI A. LPN 7/18/1960 3 MILL RD. JAMESBURG NJ 08831 SUSPENSION 1/20/2004
RABAH, MOHAMMAD DMD 11/30/1978 1669684114 55 ENCLOSURE STREET NUTLEY NJ 07030 DEBARMENT 3/3/2017
RADOWITZ, MARK A. DC 9/2/1959 76 CHICHESTER RD. MONROE
TOWNSHIP
NJ 08831 DISQUALIFICATION 9/4/2007
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
104
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
RAFLA, MAGDY 10/19/1953 3 KULESSA COURT EAST BRUNSWICK NJ 08816 DEBARMENT 8/22/2011
RAHMAN, RONALD MD 5/3/1950 1437378502 20 SUSSEX AVENUE VOORHEES NJ 08043 DISQUALIFICATION 5/29/2013
RAHMAN, SAHID CHHA 1/8/1985 29 ROBIN COURT PISCATAWAY NJ 08854 DISQUALIFICATION 1/29/2018
RAIA, JOSEPH MD 7/11/1959 1225126717 56 GRAFTON AVENUE NEWARK NJ 07104 DEBARMENT 7/28/2014
RAJA, ABDUL H. 8/4/1947 53 FULHAN LANE HOLBROOK NY 11741 DISQUALIFICATION 1/29/2003
RAJU, SRINIVASA RPH 9/5/1971 115 RIVERWALK WAY D2 CLIFTON NJ 07014 DISQUALIFICATION 7/20/2017
RAMACHANDRA,
NANDAVAR
MD 5/1/1952 1235219809 741 ROUTE 18 S. EAST BRUNSWICK NJ 08816 DEBARMENT 4/18/2014
RAMANADHAM, ARUNA R. MD 1/7/1946 1609157692 9 MOUNTAINVIEW DRIVE LIVINGSTON NJ 07039 DEBARMENT 1/12/2000
RAMAS, EDWIN L. LPN 5/18/1956 789 MITCHEL AVENUE UNION NJ 07083 DEBARMENT 7/17/2009 7/17/2014
RAMIREZ, MARIELA CHHA 5/15/1961 775 EAST 3RD AVENUE, APT. A ROSELLE NJ 07203 DEBARMENT 1/9/2018
RAMOS, JEANETTE CHHA 8/24/1989 234 WILMONT AVENUE CAMDEN NJ 08105 DISQUALIFICATION 5/2/2017
RAMOS, REYNALDO 12/22/1968 52 ABINGTON CT. MAYS LANDING NJ 08330 DEBARMENT 8/12/2013
RAMOS, ROLANDO 5/13/1977 85 SHERMAN AVENUE TEANECK NJ 07666 DISQUALIFICATION 2/20/2004
RAMPERSAD,
LAKSHMINARINE
8/20/1953 11 APPLETREE LANE LANDING NJ 07850 SUSPENSION 12/20/2000
RANCOCAS VALLEY
ANESTHESIA
700 ROUTE 130 NORTH CINNAMINSON NJ 08077 SUSPENSION 8/20/2003
RAND, DOV MD 2/10/1965 1043311145 667 EAGLE ROCK AVENUE WEST ORANGE NJ 07052 SUSPENSION 2/15/2012
RAND, DOV MD 2/10/1965 1043311145 667 EAGLE ROCK AVENUE WEST ORANGE NJ 07052 DEBARMENT 9/3/2013
RAND, DOV MD 2/10/1945 1043311145 840 STONEWALL CT FRANKLIN LAKES NJ 07417 DEBARMENT 5/7/2014
RAND, ELIAS 11/5/1932 1401 OCEAN AVENUE BROOKLYN NY 11230 DISQUALIFICATION 6/1/1993
RAO, MALINI MD 4/26/1975 1649456005 444 WASHINGTON
BOULEVARD
JERSEY CITY NJ 07310 DISQUALIFICATION 9/12/2016
RASCHID, SOHAEL MD 1/12/1957 1104851369 1126 KENNEBEC DRIVE CHAMBERSBURG PA 17201 DISQUALIFICATION 11/20/2015
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
105
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
RASNER, STEVEN DMD 7/15/1954 1114022803 1055 NORTH PEARL ST BRIDGETON NJ 08401 DISQUALIFICATION 10/16/1984 4/5/2018
RASOULINEJAD, ZAHREH T. DDS PO BOX1217 ALPINE NJ 07620 SUSPENSION 10/20/2003
RATCHFORD, WILLIAM B. MD 2/13/1945 PO BOX 2063 GLENVIEW IL 60025 SUSPENSION 6/4/1998
RAUH - BRIGHAM, SUSAN RN 8/24/1956 4 BRECKENRIDGE DRIVE SHAMONG NJ 08088 SUSPENSION 5/20/2001
RAVAL, KAWU 600 PAVONIA AVENUE JERSEY CITY NJ 07306 SUSPENSION 12/1/1998
RAVIN, JOHN M. MD 7/29/1938 9600 STERLING RIDGE
AVENUE
LAS VEGAS NV 89129 SUSPENSION 2/19/2004
RAY, DEBRA RN 5/14/1952 32 KAYWIN AVENUE HAWTHORNE NJ 07506 SUSPENSION 2/19/2004
RAYNOR, MARCELLA 8/27/1952 660 BROAD STREET, APT. 811 HARRISBURG PA 17102 DISQUALIFICATION 11/20/2015
RAZIQ, RAFIK 1/1/1960 NORTHERN STATE PRISON NEWARK NJ 07115 DISQUALIFICATION 7/1/2002
REA, MICHAEL MD 444 MANSFIELD AVENUE HADDONFIELD NJ 08033 DEBARMENT 3/11/2001 DECEASED
REATH, ERIN R. RN 10/3/1960 7705 SABRE DRIVE KNOXVILLE TN 37919 SUSPENSION 8/18/2005
REAVES, LORI A. MD 12/4/1960 1417959503 FPC ALDERSON - GLEN RAY RD ALDERSON WV 24910 DISQUALIFICATION 3/7/2014
REBA, GARY J. DDS 2/17/1947 1285852541 TITUS LANE PLAINSBORO NJ 08536 SUSPENSION 12/20/2007
RECOVERY SYSTEMS INC. 476 CLIFTON AVENUE CLIFTON NJ 07011 SUSPENSION 5/8/2003
REDDEN, DAYJA CHHA 8/1/1989 1822 SOUTH 7TH STREET CAMDEN NJ 08104 DISQUALIFICATION 1/23/2018
REDNOR, GERALD B. 101 KENSINGTON AVENUE TRENTON NJ 08618 DISQUALIFICATION 6/1/1993
REDONDO, ILEANA MD 6/4/1932 2421 ROSETTE STREET FORT LEE NJ 07024 DISQUALIFICATION 4/23/2002
REED, JUDY 233A MUHAMMAD ALI
AVENUE
NEWARK NJ 07108 DISQUALIFICATION 12/15/2005
REED, STEPHAN NILS DC 7/14/1942 4722 EAST DELL RD PHOENIX AZ 85026 DISQUALIFICATION 6/1/1993
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
106
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
REEVES, WILBURN C. CREEK RD. BRICK NJ 08724 DISQUALIFICATION 8/10/2007
REGO, RAMON MD 11/13/1961 1033227459 6701 BERGENLINE AVENUE WEST NEW YORK NJ 07093 DEBARMENT 3/19/2012 2/16/2017
REHAN, ZAHEER A. 280 HENDERSON STREET JERSEY CITY NJ 07302 DISQUALIFICATION 5/10/1999
REHMAN, FAROOQ MD 1/25/1954 1467581827 225 MAY STREET, SUITE D-1 EDISON NJ 08837 SUSPENSION 4/20/2016 2/9/2017
REHMAN, FAROOQ MD 1/25/1954 1467581827 225 MAY STREET, SUITE D-1 EDISON NJ 08837 DEBARMENT 11/13/2015
REID, PEACHES CNA 11 RUTGERS STREET IRVINGTON NJ 07111 DISQUALIFICATION 4/1/2002
REINHARD, BARBARA 704 REED COURT FLEMINGTON NJ 08822 DISQUALIFICATION 7/9/2007
REITER, RAYMOND D. MD 1/21/1955 1841447380 405 MURRAY HILL PKWY,
#1023
E. RUTHERFORD NJ 07073 DISQUALIFICATION 10/22/2001
RENNER, ALLISON 1/27/1977 1210 OAK ROAD MANASQUAN NJ 08736 DISQUALIFICATION 3/28/2017
RENZI, CAROLINE M. DO 247 CENTER ST TRENTON NJ 08611 DISQUALIFICATION 12/4/1991
RESTORATION PHARMACY 1385 STUYVESANT AVENUE UNION NJ 07083
DEBARMENT
1/16/2009
REVAN-LEWIS, CHAUNDEL CHHA 2/6/1981 26 NANCY LANE PISCATAWAY NJ 08854 DISQUALIFICATION 2/8/2017
REYES, DANNIELL DC 4/21/1960 1124053905 5262 HAMILTON S SAYLORSBURG PA 18353 DISQUALIFICATION 11/20/2015
REYES, MARIA CHHA 6/13/1987 1207 ATLANTIC AVENUE CAMDEN NJ 08104 DEBARMENT 8/29/2017
REYES-ARIAS, ARCADIO 1/12/1971 286 SUSSEX AVENUE NEWARK NJ 07107 DISQUALIFICATION 2/11/2016
REZNIKOVA, YELENA CHHA 9/28/1977 73 MADISON GARDENS OLD BRIDGE NJ 08857 DEBARMENT 6/12/2017
RGN PHARMACY 1790840130 22 ELIZABETH AVENUE NEWARK NJ 07108 SUSPENSION 8/17/2007
RHODES, SARE MAE DMD 2/6/1978 1750572996 161 BRIDGE STREET TUNKHANNOCK PA 18657 DISQUALIFICATION 12/29/2015
RIACHI, LABIB MD 9/4/1968 1801846597 319 MASSACHUSETTS STREET WESTFIELD NJ 07090 DISQUALIFICATION 2/9/2017
RIACHI, LABIB MD 9/4/1968 1801846597 42 RUTGERS AVENUE COLONIA NJ 7067 DEBARMENT 2/9/2018
RICCIARDI, JUDE CHHA 12/6/1969 1452 45TH STREET NORTH BERGEN NJ 07047 SUSPENSION 6/20/2002
RICCIO, PETER RPH 4/16/1953 17 CASALE DRIVE, APT. R2 WARREN NJ 07059 DISQUALIFICATION 5/12/2016
RICH, LEO CEDAR LANE TEANECK NJ 07666 DISQUALIFICATION 6/1/1993
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
107
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
RICHARDS, AARON COUNSEL
OR
23 WYCOFF STREET DEAL NJ 07723 SUSPENSION 2/20/2001
RICHARDSON, YALONDA CHHA 7/15/1980 52 2ND AVENUE TOMS RIVER NJ 08757 DISQUALIFICATION 2/20/2017
RICHLINE, AMANNDA DPM 5/5/1969 1013040435 4 GREENWICH STREET BELVIDERE NJ 07823 DEBARMENT 7/22/2017
RICHMAN, HOWARD P. DPM 12/31/1951 502 N BLACK HORSE PIKE WILLIAMSTOWN NJ 08053 DISQUALIFICATION 4/15/1993
RICHSTONE, GEOFFREY MD 9/17/1938 PO BOX 38, FCI FORT DIX NJ 08640 SUSPENSION 6/20/2002
RIGGI, JOSEPH MD 8/5/1970 1265436638 36 VARDON WAY FARMINGDALE NJ 07727 DEBARMENT 12/9/2015
RIGO, BLADIMIR 3/22/1940 FCI-FORT DIX, PO BOX 2000 JOINT BASE MDL. NJ 08640 DISQUALIFICATION 5/12/2016
RILEY, BRIDGETT PHARM
TECH
1801 EGG HARBOR RD. LINDENWOLD NJ 08021 SUSPENSION 3/20/2003
RIMERMAN, VALERY MD 4/29/1939 43 DEMAREST AVENUE CLOSTER NJ 07624 SUSPENSION 12/20/2006 DECEASED
RIOS, GUSTAVO ERNESTO MD 9/13/1967 1780648295 127 TWEED DRIVE JACKSONVILLE NC 28540 DEBARMENT 10/11/2011
RIOS, JOSE MD 8/22/1927 175 SUMMER AVENUE NEWARK NJ 07104 SUSPENSION 5/14/1998
RIPPS, DANIEL DDS 9/3/1948 1124293659 1330 CALHOUN STREET TRENTON NJ 08618 DISQUALIFICATION 12/1/1995
RIVERA, DAISY CHHA 10/20/1994 329 LINE STREET CAMDEN NJ 08103 DISQUALIFICATION 1/29/2018
RIVERA, JACQUELINE CHHA 6/11/1977 418 12TH STREET, APT. #1 UNION CITY NJ 07087 DISQUALIFICATION 1/23/2018
RIVERA, JOSSELIN 9/14/1979 251 MT. VERNON ST. CAMDEN NJ 08103 DISQUALIFICATION 1/27/2006
RIVERA, KAREN CHHA 9/23/1989 209 NILES STREET, APT. 1 ELIZABETH NJ 07202 DEBARMENT 2/20/2017
RIVERA, NICOLE AKA
CRESTA, NICOLE
RN 2/11/1983 2009 KICKAPOO TERRACE VINELAND NJ 08361 DISQUALIFICATION 3/28/2017
RIVERA, VIVIANIS CHHA 7/5/1984 519 BRUNSWICK AVENUE TRENTON NJ 08638 DISQUALIFICATION 10/20/2017
RIZVI, SAIYID PHD 100 CRAIG RD., SUITE 104 MANALAPAN NJ 07726 SUSPENSION 4/18/1997
RIZZO, KENNETH RPH 2/16/1965 110 WELLS FARM RD. GOSHEN NY 10924 SUSPENSION 5/19/2005
RIZZUTO, MARY F. LCSW 1/24/1960 1851499891 16 HOLLY HILL DRIVE TOMS RIVER NJ 08753 DISQUALIFICATION 4/22/2012
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
108
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ROBACK, MARY LPN 7/29/1954 2517 DUNKSFERRY ROAD,
APT. L203
BENSALEM PA 19020 DISQUALIFICATION 6/20/2018
ROBALINO, JOFFRE MD 6/12/1967 1770634404 PO BOX 1000 CUMBERLAND MD 21501 DISQUALIFICATION 5/28/2013
ROBBERSON JR., KENNETH 8/17/1969 3404 SHORELINE DRIVE WALL TOWNSHIP NJ 07719 DISQUALIFICATION 6/16/2017
ROBBINS, GORDON J. 447 UNION AVENUE PATERSON NJ 07522 DISQUALIFICATION 4/30/1987
ROBBINS, RICHARD G. MD 7/29/1963 551 MILLBURN AVE. SHORT HILLS NJ 07078 SUSPENSION 2/19/2004
ROBERTS, ELIANE CHHA 9/10/1962 380 PARK AVENUE, APT. C5 ORANGE NJ 07050 DISQUALIFICATION 7/14/2017
ROBERTS, JAMES RN 5/29/1969 235 PENN AVENUE DOVER NJ 07801 DISQUALIFICATION 7/22/2017
ROBINSON, KIM 2/23/1956 594 WALNUT STREET ELIZABETH NJ 07201 SUSPENSION 2/3/2003
ROBINSON, TRENNAJIA CHHA 2/18/1994 89 FOURTH STREET, APT. #43 PASSAIC NJ 07055 DISQUALIFICATION 5/2/2017
ROBINSON, VINCENT 3/10/1968 62 MAPLE AVENUE IRVINGTON NJ 07111 DEBARMENT 3/13/2009 3/13/2014
ROBINSON, WANDA J. 7/23/1944 150 MELROSE AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 9/4/1986
RODENBERG, THOMAS MD 4/6/1959 1720280183 DESOTO ANNEX, 13617
SOUTHEAST HWY 70
ARCADIA FL 34266 DISQUALIFICATION 12/29/2015
RODRIGUEZ, ARACELY CHHA 4/18/1975 1039 NORTH 35TH STREET CAMDEN NJ 8105 DEBARMENT 5/31/2018
RODRIGUEZ, BEATRIZ 10/8/1967 109 GREENBRIAR AVENUE
BOX157
RICHLAND NJ 08350 SUSPENSION 10/18/2001
RODRIGUEZ, DARIELI CHHA 5/22/1991 545 NEWTON LAKE DRIVE COLLINGSWOOD NJ 08107 DISQUALIFICATION 9/26/2017
RODRIGUEZ, FERNANDO MD 6/10/1950 122 S. MONTFORT DRIVE BELLE MEAD NJ 08502 DEBARMENT 4/6/2004
RODRIGUEZ, MELENYS CHHA 6/26/1990 18 WINDING WOOD DRIVE SAYREVILLE NJ 08872 DISQUALIFICATION 8/29/2017
RODRIGUEZ, NICOLE CHHA 10/13/1992 658 DELSEA DRIVE PITMAN NJ 08071 DEBARMENT 4/6/2018
RODRIGUEZ, RAMON R. 1/13/1939 100 MANHATTAN AVENUE JERSEY CITY NJ 07307 DISQUALIFICATION 3/17/1986 DECEASED
RODRIGUEZ, RONALD J. LPN 5/20/1966 7 EASTERN LANE WILLINGBORO NJ 08046 SUSPENSION 12/20/2006
RODRIGUEZ, RONALD J. LPN 5/20/1966 7 EASTERN LANE WILLINGBORO NJ 08046 DEBARMENT 7/11/2018
ROGERS, JAMES G. 2/22/1937 49 WESTERN PARKWAY IRVINGTON NJ 07111 SUSPENSION 4/11/2006
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
109
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ROHAUS, ROBERT 301 LILAC COURT BRIDGEWATER NJ 08807 SUSPENSION 8/25/2000
ROHE, PAUL DPM 11/16/1956 24 FAIRWAY DRIVE GREEN BROOK NJ 08812 SUSPENSION 11/20/2006
ROLON JR., ORLANDO 11/4/1957 1239 DUPONT STREET CAMDEN NJ 08105 DISQUALIFICATION 11/12/2009
ROMANAZZI, THOMAS 612 MYRTLE AVENUE MANASQUAN NJ 08786 DISQUALIFICATION
ROMAN-CISSE, DENISE PHARM
TECH
12/16/1983 9 SECOND AVENUE NEWARK NJ 07104 DEBARMENT 4/12/2012
ROMANOWSKI, STEVEN PO BOX 1011 UNION NJ 07083 DISQUALIFICATION
ROMERO, IVAN J. RPH 4/14/1969 1003089343 USP CANAAN, PO BOX 300 WAYMART PA 18472 DISQUALIFICATION 8/8/2011
ROMILLO, JOSE E. MD 3/1/1945 1467544155 954 FISCHER BOULEVARD TOMS RIVER NJ 08753 DISQUALIFICATION 8/16/2011
RONAN, KATHLEEN RN 17 HENRY STREET SAYERVILLE NJ 08872 SUSPENSION 10/18/2001
RONCAL JR., MARIO 4/2/1951 901 RIFLE CAMP RD. WOODLAND PARK NJ 07424 DISQUALIFICATION 8/20/2014
RONE, FELICIA CHHA 3/19/1978 2702 SHETLAND WAY WESTVILLE NJ 08093 DISQUALIFICATION 7/14/2017
ROQUE, JOSE RAMON MD 317 60TH STREET W. NEW YORK NJ 07903 DISQUALIFICATION 8/1/1996
ROSA, EDDIE MD 3/3/1966 1215045869 796 MT. PROSPECT AVENUE NEWARK NJ 07104 SUSPENSION 2/15/2012
ROSA, EDDIE MD 3/3/1966 1215045869 117-119 THIRD AVENUE 2 NEWARK NJ 07104 DISQUALIFICATION 1/26/2015
ROSA, EDDIE MD 3/3/1966 1215045869 117-119 THIRD AVENUE NEWARK NJ 07104 DEBARMENT 11/21/2016
ROSA, EDDIE MD 3/3/1966 1215045869 796 MT. PROSPECT AVENUE NEWARK NJ 07104 DISQUALIFICATION 9/17/2013
ROSADO, EDITH CHHA 10/29/1968 326 GREGORY AVENUE PASSAIC NJ 07055 DISQUALIFICATION 2/8/2017
ROSANIA, NICHOLAS G. DC 5/28/1968 1 COBBLESTONE LANE LONG VALLEY NJ 07853 SUSPENSION 10/20/2003
ROSARIO, JASON CHHA 2/10/1993 133 RUTGERS PLACE NUTLEY NJ 07110 DEBARMENT 11/1/2017
ROSE, RADCLIFFE RN/PHAR
M TECH
8/10/1965 99 GROVE AVENUE MAYWOOD NJ 07607 DISQUALIFICATION 2/21/2018 PERMANENT
ROSEN, BURTON DDS 9/22/1930 1939 ROUTE 70 EAST CHERRY HILL NJ 08003 DEBARMENT 5/24/1999
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
110
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ROSEN, JAY MD 11/30/1946 1720139736 3 HIDDEN ACRES DRIVE VOORHEES NJ 08043 DISQUALIFICATION 8/22/2016 PERMANENT
ROSENBERG, MARK RN/APN 4/3/1954 1407829096 19 BRANDYWINE DRIVE MARLTON NJ 08052 DISQUALIFICATION 11/21/2016
ROSENBLIT, ERIN RN/APN 8/17/1955 654 8TH STREET ABSECON NJ 08201 DEBARMENT 6/5/2018
ROSENFARB, ANDREW ACCUPU
NCTURIST
1/12/1972 332 SOUTH AVENUE EAST WESTFIELD NJ 07090 SUSPENSION 3/20/2005
ROSENSWEET, MARTIN DPM 6/27/1957 FORT DIX FCI, PO BOX 38 FORT DIX NJ 08640 DEBARMENT 7/18/2002
ROSERO, BENITO MD 11/18/1937 107 E. MANTUA AVENUE WEHONAH NJ 08090 SUSPENSION 2/2/1998
ROSERO, BENITO MD 11/18/1937 109 AMBLER RD. CHERRY HILL NJ 08002 SUSPENSION 1/6/1999
ROSS, BERNARD MD 5/8/1914 30 E. PASSAIC STREET MAYWOOD NJ 07607 DEBARMENT 10/5/1999
ROSS, DOUGLAS AKA
SHAW, RICKY
12/10/1972 123 N. 19TH STREET EAST ORANGE NJ 07017 DISQUALIFICATION 10/14/2005
ROSS, JONATHAN MD 4/1/1954 11 TEAK COURT CHERRY HILL NJ 08003 DISQUALIFICATION 6/19/2000
ROSS, JOSIE B. RN 6/27/1955 25 GRAND AVENUE HACKENSACK NJ 07601 SUSPENSION 7/20/2004
ROSS, RUBY LPN 10/15/1964 149 RIDGE AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 12/5/2017
ROSSI, ANGELA LPN 12/18/1976 813 HAZELTON AVENUE LANOKA HARBOR NJ 08734 DISQUALIFICATION 6/5/2017
ROSSNICK, GERALD DDS 1/29/1923 868 BROADWAY BAYONNE NJ 07002 DISQUALIFICATION 12/1/1988
ROTHENBERG, HOWARD DMD 4/14/1951 1437223898 11 OAK SPRING ROAD WEST NYACK NY 10994 DISQUALIFICATION 12/29/2017
ROTHSTEIN, JEFFREY DMD 12/4/1964 1366677544 326 BROAD STREET, SUITE 1 RED BANK NJ 07701 DISQUALIFICATION 7/20/2017 9/22/2017
ROTWEIN, PAUL S. DDS 6/24/1957 220 E. 63RD ST., APT. 8F NEW YORK NY 10021 DEBARMENT 4/20/2003
ROUNTSEV, ANATOLI CHHA 3/25/1962 409 RIVERVIEW DRIVE TOTOWA NJ 07512 SUSPENSION 11/4/2014
ROUNTSEV, ANATOLI CHHA 3/25/1962 406 RIVERVIEW DRIVE TOTOWA NJ 07512 DISQUALIFICATION 2/11/2016
ROUSE, JODY LPN 9/2/1977 189 BROWNIES RD. SHIPPENVILLE PA 16254 DISQUALIFICATION 11/20/2015
ROUSSIS, NICHOLAS MD 6/29/1968 1497749089 4735 HYLAN BOULEVARD STATEN ISLAND NY 10312 DEBARMENT 7/1/2017
ROWE, ELIZABETH LPN 4/10/1982 6 WINDING WOOD DRIVE,
APT. 1B
SAYREVILLE NJ 08872 DEBARMENT 6/28/2018
ROYSTER, TAHNESHA CHHA 4/15/1988 30 RIDGE AVENUE NEPTUNE NJ 07753 DEBARMENT 8/24/2017
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
111
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ROZO, GLADYS 374B HAMILTON STREET SOMERSET NJ 08873 SUSPENSION 5/14/2007
ROZVAGA, NADEZHDA 11/4/1946 155 ALEXAUKEN CREEK RD. LAMBERTVILLE NJ 08530 SUSPENSION 8/20/2009
RUANE, JOSEPH T. DC 8/16/1955 314 WILLOW DRIVE LITTLE SILVER NJ 07739 SUSPENSION 1/8/1997
RUBINSTEIN, CHARLES RPH 45 LAUREL AVENUE LINWOOD NJ 08221 SUSPENSION 8/20/2006
RUDOLPH, HERBERT MD 11/9/1954 1871633370 317 EAST MAIN STREET TUCKERTON NJ 08087 DEBARMENT 9/14/2016
RUFFIN, SHARALYN CHHA 12/12/1980 OAKDALE VILLAGE TRAILER
#52
CRANBURY NJ 08512 DISQUALIFICATION 2/8/2017
RUGGIERO, PAULA E. RN 12/8/1970 29 PARKWAY DRIVE WESTVILLE NJ 08093 SUSPENSION 10/18/2001
RUIZ, DORIS 909 WEST 7TH STREET PLAINFIELD NJ 07063 SUSPENSION 5/14/2007
RUIZ, JENNIFER 4/14/1983 38 S. BRIDGEBORO STREET DELRAN NJ 08075 DISQUALIFICATION 11/21/2016
RULDAN, THOMAS LPN 301 OHIO AVENUE PHILLIPSBURG NJ 08865 SUSPENSION 5/20/2001
RUMMA, CHRISTINE
DONNA
164 STARBOARD STREET FORKED RIVER NJ 08731 DISQUALIFICATION 5/26/2000
RUSH, DAVID A. 6/25/1959 5755 PFEIFER CIRCLE GERMANSVILLE PA 18053 SUSPENSION 4/19/1999
RUSH, DAVID A. 6/25/1959 5755 PFEIFER CIRCLE GERMANSVILLE PA 18053 DISQUALIFICATION 10/11/2000
RUSHING, GARY DC 5/20/1959 1538315478 70 BROAD STREET, SUITE B MATAWAN NJ 07747 SUSPENSION 1/20/2002
RUSSELL JR., BERTRAM R. MD USP HAZELTON, PO BOX 2000 BRUCETON MILLS WV 26525 DEBARMENT 12/28/2014
RUSSELL, FERNESE D. CNA 666 E. 26TH STREET PATERSON NJ 07504 DEBARMENT 3/24/2002
RUSSELL, ROBERT J. DC 3/26/1962 1645 B-BLACKWOOD
CLEMENTON ROAD
BLACKWOOD NJ 08012 DISQUALIFICATION 10/2/1995
RUSSOMANNO, RAYMOND MD 5/30/1943 1093702532 350 BLOOMFIELD AVENUE BLOOMFIELD NJ 07003 DEBARMENT 11/28/2007
RUTA, EUGENIO DC 4/14/1961 189 6TH AVENUE LONG BRANCH NJ 07740 SUSPENSION 7/21/2008
RUTIGLIANO, MICHAEL MD 1740348077 1 SEARS DRIVE PARAMUS NJ 07652 DISQUALIFICATION 9/19/2016
RX 2000 PHARMACY, INC. 2125A KENNEDY BOULEVARD JERSEY CITY NJ 07305 DISQUALIFICATION 1/2/2000
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
112
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
RYAN, GERALDINE RN 2/5/1956 228 RIDGE AVENUE LAKEWOOD NJ 08701 SUSPENSION 2/20/2002
RYAN, JAMES 267 SEACLIFF AVENUE SEACLIFF NY 11579 DISQUALIFICATION 4/1/1996 4/1/2004
RYAN, MICHELE K. LPN 7/25/1969 656 WHITE HORSE PIKE HAMMONTON NJ 08037 SUSPENSION 3/20/2002
RYBALOV, SEMEN CHHA 11/5/1945 BERGEN COUNTY JAIL, PO BOX
0369
HACKENSACK NJ 07601 DISQUALIFICATION 10/28/2015
S. RESES APOTHOCARY 6522 VENTNOR AVENUE VENTNOR NJ 08406 DISQUALIFICATION
SAADY, JACK R. RPH 7/18/1960 281 ROUND HILL DRIVE FREEHOLD NJ 07728 DISQUALIFICATION 7/11/2000
SABA - KHALIL, ROSALY MD 10/10/1939 531 SUMMIT AVENUE FRANKLIN LAKES NJ 07417 DISQUALIFICATION 7/10/1995
SABATE, NEONITA RN 6/3/1956 PO BOX 4004 CLINTON NJ 08809 DISQUALIFICATION 8/27/2001
SABBAGHZADEH, ANDREW
A.
9/29/1981 108 BRANDON RD. EAST SYRACUSE NY 13057 SUSPENSION 3/20/2012
SABIDO, BENJAMIN A. MD 3/30/1952 1720159916 805 11TH STREET UNION CITY NJ 07087 DISQUALIFICATION 3/26/2015
SACCA, COLLEEN RN 11/11/1969 310 GARFIELD AVENUE PALMYRA NJ 08065 SUSPENSION 5/20/2004
SACHER, PHILIP 558 ANDERSON AVENUE CLIFFSIDE PARK NJ 07010 DISQUALIFICATION 5/6/1986
SADARANGANI, BHAGWAN MD 7/12/1945 1386790665 240 LYNCREST RD. ENGLEWOOD CLIFF NJ 07632 DISQUALIFICATION 2/28/2011
SADLER, RUFUS MD 3/13/1956 1316935406 2 LAWRENCE STREET MOUNT VERNON NY 10552 DISQUALIFICATION 6/3/2016
SAEED, MOHAMMED 1507 FINNEGANS LANE NEW BRUNSWICK NJ 08902 DISQUALIFICATION 11/16/1998
SAFIER, GARY DO 2/21/1943 1558478529 8 QUARRY COURT, #3 RANDOLPH NJ 07869 DEBARMENT 4/1/2016
SALAAM, ABDUL J. MD 1153 SOUTH ORANGE
AVENUE
NEWARK NJ 07103 DISQUALIFICATION 8/7/1997
SALAGA, JENNIFER RN 3/29/1981 248 WARD AVENUE BORDENTOWN NJ 08505 DISQUALIFICATION 6/28/2017
SALAMI, ADEMOLA T. HARVARD AVENUE HILLSIDE NJ 07205 DISQUALIFICATION 9/15/2008
SALARTASH, KHASHAYAR MD 8/11/1966 1457376006 112 POND LANE LINWOOD NJ 08221 SUSPENSION 10/27/2009 10/7/2011
SALEMA, JOSEPH 4/25/1948 101 EAST ELM STREET WENONAH NJ 08090 DISQUALIFICATION 4/4/1998
SALITA, CONRAD C. MD 4/27/1932 1 N. VALLEY AVENUE VINELAND NJ 08360 DISQUALIFICATION 12/29/1995
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
113
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SALKIND, SCOTT A. DO 8/10/1953 1750401949 611 KINGS CROFT CHERRY HILL NJ 08034 SUSPENSION 9/14/2000
SALOMONE, JOSEPH DC 3/11/1968 1609019140 156 FRANKLIN AVENUE NUTLEY NJ 07110 DISQUALIFICATION 7/20/2015
SALT & PEPPER INC. 24 BRANFORD PLACE NEWARK NJ 07102 DISQUALIFICATION 5/9/1994
SALUJA, DHANBIR MD 8/8/1941 1023045010 230 JEFFERSON STREET NEWARK NJ 07105 DEBARMENT 8/24/2013
SALUJA, DHANBIR MD 8/8/1941 1023045010 230 JEFFERSON STREET NEWARK NJ 07105 DISQUALIFICATION 6/3/2016
SALVATORE JR., THOMAS 201 HAMILTON AVENUE TRENTON NJ 08609 DISQUALIFICATION
SAMAN, AIAD L. 47 CENTER PLACE STATEN ISLAND NY 10306 DISQUALIFICATION 3/25/2009
SAMI, ASHRAF 64 CARUTH AVENUE, APT. 66 ELMWOOD PARK NJ 07407 DISQUALIFICATION 5/24/2017
SAMILLAN, HANS CHHA 8/22/1984 3-3 SYDNEY WAY LONG BRANCH NJ 07740 DISQUALIFICATION 2/8/2017
SAMUEL, DELORIS PO BOX 4004 CLINTON NJ 08809 DISQUALIFICATION 5/2/2008
SANCHEZ, MAURICE 243 PROSPECT AVENUE NORTH ARLINGTON NJ 07031 DISQUALIFICATION 1/1/2011 4/30/2012
SANDERLIN, KATHLEEN RN 4/16/1960 824 SANIKAN TRAIL SOUTHAMPTON NJ 08088 SUSPENSION 10/18/2001
SANDERS, DENISE PHARM
TECH
3/21/1953 4 DREXEL COURT LINDENWOLD NJ 08021 DISQUALIFICATION 7/12/1995
SANDERS, MICHAEL THERAPIS
T
8/29/1964 4 CHERRY RD. NEWTON NJ 07860 SUSPENSION 10/19/2006
SANDERSON, LYNN LPN/RN 7/8/1956 120 GATES MILL COURT TRENTON NJ 08690 SUSPENSION 6/20/2005
SANDFORD'S PHARMACY 128 MAIN STREET MATAWAN NJ 07747 DISQUALIFICATION 1/5/1999
SANDIEGO, NARDO MD 10/26/1935 1578508115 4 HEATHER HILL LANE SUFFERN NY 10901 DEBARMENT 10/8/2013
SANGALANG, ALEX RN 9/18/1955 21 LISA DRIVE HAZLET NJ 07730 DISQUALIFICATION 6/5/2017
SANGHERA, ANIL MD 1/14/1950 105 PHEASANT FIELD LANE MOORESTOWN NJ 08057 DISQUALIFICATION 5/20/2009
SANICO, ELAINE D. DPM 122 BRIGHT ST., #1W JERSEY CITY NJ 07302 SUSPENSION 11/19/1997
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
114
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SANTA MARIA, DONNA L. RN 7/3/1954 618 CINDER RD. EDISON NJ 08820 DISQUALIFICATION 7/18/2001
SANTANA, SONIA CHHA 5/27/1939 569 E. 33RD STREET PATERSON NJ 07613 DISQUALIFICATION 3/28/2001
SANTANGELO, FRANK MD 10/4/1969 1881785293 705 HAMBURG TURNPIKE WAYNE NJ 07470 DISQUALIFICATION 11/22/2016
SANTANGELO, FRANK MD 10/4/1969 1881785293 705 HAMBURG TURNPIKE WAYNE NJ 07470 DISQUALIFICATION 3/13/2017
SANTANIELLO, RICHARD J. 3/3/1970 5 BUGLE COURT HOWELL NJ 07731 SUSPENSION 3/20/2002
SANTIAGO JR., EDDIE MD 9/2/1969 1497796973 300 SECOND AVENUE LONG BRANCH NJ 07740 DISQUALIFICATION 11/1/2014
SANTIAGO, RANALDO GIBBSBORO RD. LINDENWOLD NJ 08021 DISQUALIFICATION 8/10/2007
SANTIAGO, REYNALDO MD 3/8/1945 1502A MARCY PLACE PHILADELPHIA PA 19115 DISQUALIFICATION 6/16/1997
SANTIAGO, RUTH M. CHHA 2/1/1967 289 BROADWAY, APT. E NEWARK NJ 07104 SUSPENSION 7/19/2001
SANTIAGO, VANESSA 35 AMHERST RD. SOUTH TOMS RIVER NJ 08757 DEBARMENT 5/31/2006
SANTIAGO-JIMINEZ,
HERIBERTO
4/12/1955 396 WOODLAND AVENUE SOUTH AMBOY NJ 08879 DISQUALIFICATION 9/19/2011
SANTOS - ARIAS, SIMON MD 10/28/1941 1497721062 10305 NW 7TH COURT PLANTATION FL 33324 DEBARMENT 8/18/2016
SAPERSTEIN, ALAN 30 HIGHLAND RD-DIX HILLS LONG ISLAND NY 11746 DISQUALIFICATION 3/1/1987
SARKODIE, ALEX MD 7/27/1960 1598870271 516 YORKTOWN ROAD UNION NJ 07083 DISQUALIFICATION 9/14/2016
SARKODIE, ALEX MD 7/27/1960 1598870271 516 YORKTOWN ROAD UNION NJ 07083 DISQUALIFICATION 6/5/2017
SATCHER, WILLIAM 558 ANDERSON AVENUE CLIFFSIDE PARK NJ 07010 DISQUALIFICATION
SAUL, STEPHEN L. DPM 4/2/1971 76 W. JIMMIE LEEDS RD. ABSECON NJ 08201 DISQUALIFICATION 7/18/2001 PERMANENT
SAUL, STEPHEN L. DPM 4/2/1971 9 SEASIDE COURT MARGATE CITY NJ 08402 DISQUALIFICATION 9/12/2016 PERMANENT
SAYED, SAQUIB MD 9/14/1965 1609054360 4 TURTLE HOLLOW COURT SICKLERVILLE NJ 08081 DEBARMENT 4/29/2016
SAYED-BAKHATY, ABDEL MD 403 HARMON TOWERS SECAUCUS NJ 07094 SUSPENSION 4/26/1995
SAYEGH, RICKY MD 4/1/1975 1346274966 4 FOWLER AVENUE YONKERS NY 10701 DISQUALIFICATION 9/19/2016
SAYEGH, RICKY MD 4/1/1975 1346274966 390 FORT HILL ROAD SCARSDALE NY 10583 DEBARMENT 11/20/2017
SBARRA, SAMUEL DC 9/3/1958 1205913100 PARK AVENUE NUTLEY NJ 07110 SUSPENSION 10/20/2008 1/20/2015
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
115
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SCARPITTA, JANET 9/2/1964 92 PEABODY PLACE NEWARK NJ 07104 DISQUALIFICATION 6/15/2001
SCERBO, ERNEST J. MD 10/9/1909 26-10 BROADWAY SUITE 103 FAIR LAWN NJ 07410 DISQUALIFICATION 6/1/1993 DECEASED
SCHECHTER, MARVIN OD 1063420453 100 YORKTOWN DR. MT. LAUREL NJ 08054 DISQUALIFICATION 6/1/1993
SCHEIN, HERBERT W. MD 2/22/1917 1027 HOOPER AVENUE TOMS RIVER NJ 08753 DISQUALIFICATION 5/30/1991
SCHEINER, DAVE E. DPM 12/14/1950 910 BONAPARTE COURT PHILADELPHIA PA 19107 SUSPENSION 7/22/1999
SCHENKEL, CATHERINE
MICHELLE
RN 10/6/1956 87 IRVING AVENUE, APT. 3 LIVINGSTON NJ 07039 DISQUALIFICATION 6/20/2009
SCHENKEL, CATHERINE
MICHELLE
RN 10/6/1956 87 IRVING AVENUE, APT. 3 LIVINGSTON NJ 07039 SUSPENSION 5/30/2010
SCHERING SALES
CORPORATION
2000 GALLOPING HILLS ROAD KENILWORTH NJ 07033 SUSPENSION 10/20/2005
SCHLACHTER, ANDREA 1/19/1971 42 WEST HOLLY STREET CRANFORD NJ 07016 SUSPENSION 11/20/2006
SCHLEMBACH, ANDREA APN/RN 7/26/1979 1780630418 70 COHANSEY STREET BRIDGETON NJ 08302 DISQUALIFICATION 9/12/2016
SCHLISSERMAN, HERMAN 300 48TH STREET UNION CITY NJ 07087 DISQUALIFICATION
SCHMIDT, NORINE RN 7/15/1959 78 S. ROOSEVELT SQUARE ENGLEWOOD NJ 07631 DISQUALIFICATION 7/12/2018
SCHMUCKER-KARPOW,
CELESTE
MD 4/6/1954 50 MAPLE AVENUE MORRISTOWN NJ 07960 DISQUALIFICATION 12/27/1995
SCHNEIDER, BRUCE J. DDS 11/1/1951 520 CLIFFORD AVENUE, E8 MATAWAN NJ 07747 SUSPENSION 7/20/2006
SCHNORBUS PHARMACY 351 NORTH WARREN STREET TRENTON NJ 08618 DISQUALIFICATION 8/19/1981
SCHOBERT III, WILLIAM B. 25 WELLINGTON DRIVE, #D LUMBERTON NJ 08048 DISQUALIFICATION 6/20/2009 7/14/2014
SCHRAGER, KENNETH, J. MD FCI, PO BOX 600 OTISVILLE NY 10963 SUSPENSION 6/19/2001
SCHROEDER, PETER RN 6/17/1968 18 PILGRIM WAY HAMILTON NJ 08620 DISQUALIFICATION 10/11/2017
SCHULTZ, STEVEN MD 9/16/1946 1495 EAST 92ND STREET, #2 BROOKLYN NY 11236 DISQUALIFICATION 6/9/1999
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
116
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SCHUTT, CHARLES HARDEN 21 PARMLEY RD. TINTON FALLS NJ 07724 DISQUALIFICATION 3/8/1978
SCHWARTZ, EDWARD RPH 3/5/1936 60 SIP AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 8/6/1998 RETIRED
SCHWARTZ, EDWARD RPH 3/5/1936 720 HARMON COVE TOWERS SECAUCUS NJ 07094 DISQUALIFICATION 1/17/2001 RETIRED
SCHWARTZ, EDWARD RPH 3/5/1936 1021 HERALD STREET REDLANDS CA 92374 SUSPENSION 12/20/2000 RETIRED
SCHWARTZ, GEORGE
ROBERT
MD 1/2/1942 PO BOX 1806 SANTA FE NM 87504 SUSPENSION 12/19/2007
SCHWARTZ, MURRAY DO 9/5/1943 1063573012 5 AUTUMN COURT CHERRY HILL NJ 08003 DEBARMENT 1/23/2013
SCHWARTZ, MURRAY DO 9/5/1943 1063573012 5 AUTUMN COURT CHERRY HILL NJ 08003 DISQUALIFICATION 12/5/2013
SCHWARZ, DENISE DPM 1729 PAMMEL PARK RD. WINTERSET IA 50273 SUSPENSION 2/20/2002
SCOPELLITI, ALDO R. DC 9/5/1958 1568524049 107 MONMOUTH RD. W. LONG BRANCH NJ 07764 SUSPENSION 5/12/2000
SCOTT, DEBRA 1/3/1964 2751 S. OCEAN DRIVE HOLLYWOOD FL 33019 SUSPENSION 5/20/2004
SCOTT, GLENN RN 10/8/1961 70 POLIFLY RD., APT. 105 HACKENSACK NJ 07601 SUSPENSION 10/18/2001
SCOTT, MCKENZIE LPN 5/22/1986 457 REDBANK RD. TEMPLETON PA 16259 DISQUALIFICATION 11/20/2015
SCOTT, MELVIN 11/9/1974 42 HIGHLAND TERRACE IRVINGTON NJ 07111 SUSPENSION 6/3/2001
SCULLION, FRANCES RN 20 BREAKNECK RD. OAKLAND NJ 07436 DISQUALIFICATION 7/13/1988
SCURRY, MARSHAYA PHARM
TECH
1/15/1983 1500 GARDEN DRIVE OCEAN NJ 07712 DEBARMENT 1/4/2017 6/26/2018
SEAMAN, VIVIAN RN 4/6/1960 823 TENTH STREET UNION BEACH NJ 07735 DISQUALIFICATION 9/12/2016
SEDEHI, AHMAD DMD 6/15/1949 1063634640 31 JANE DRIVE ENGLEWOOD CLIFFS NJ 07632 DEBARMENT 7/1/2017
SEGLIN, MARK PSYCH 7/11/1944 1184754632 89 LAPIS CIRCLE WEST ORANGE NJ 07052 DISQUALIFICATION 1/1/2017
SEHGAL, GAUTAM MD 12/20/1949 1497801740 8 WINDERMERE COURT LIVINGSTON NJ 07039 SUSPENSION 5/2/2016
SEHGAL, SHASHIBALA MD 12/27/1949630 FORT WASHINGTON
AVENUENEW YORK NY 10040 SUSPENSION 12/31/2000
SELIM, HANAN RPH 9/7/1968 47 NORWOOD AVENUE CLIFTON NJ 07011 SUSPENSION 5/30/2000
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
117
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SEMPLE, IVRY 724 GROVE ST IRVINGTON NJ 07111 DISQUALIFICATION 12/24/1985
SEMPLE, IVRY 472 LAKESIDE AVENUE ORANGE NJ 07050 DISQUALIFICATION 8/14/1986
SENAPE, SAVERIO MD 215 WEST 92ND STREET, 15A NEW YORK NY 10025 DISQUALIFICATION 8/5/1998
SENATORE, SALVATORE DC 2/19/1949 1073653366 342 LINCOLN DRIVE KENILWORTH NJ 07033 DISQUALIFICATION 8/19/2010
SENDER, PAUL MD 3/7/1955 1124321286 30A WEST MAPLE AVENUE MONSEY NY 10952 SUSPENSION 11/20/2006 12/22/2014
SENQUIZ, LUZ COUNSEL
OR
9/26/1951 471 HIGHLAND AVENUE, APT.
A
COLLINGSWOOD NJ 08108 SUSPENSION 4/29/2003
SENTILLES, JEAN J. MD 11/27/1945 150 W 56TH ST. N 509 NEW YORK NY 10019 DISQUALIFICATION 2/27/1992
SERENO, PATRICIA LPN/RN 7/27/1950 18 SECRETARIAT STREET HOWELL NJ 07731 SUSPENSION 9/20/2001
SERPE, JOSEPH RN 9/20/1988 459 MAIN STREET STATEN ISLAND NY 10307 DISQUALIFICATION 6/5/2017
SERRANO, KRISTINA CHHA 9/26/1995 59 ARCADIA PLACE, #B VINELAND NJ 08360 DISQUALIFICATION 2/8/2017
SESAY, CHERYL LPN 11/2/1959 12 AVA AVENUE SOMERDALE NJ 08083 SUSPENSION 10/20/2002
SESSOMS, VALERIE 12/16/1958 29 STRATFORD PLACE, APT. 6J NEWARK NJ 07108 DISQUALIFICATION 9/20/2012
SEUFERT, ANNA MARIE CHHA 5/8/1990 5139 LAKE WORTH RD. GREEN ACRES FL 33463 DISQUALIFICATION 6/19/2014
SEXTON, JILL RN 1/8/1978 5460 ROUTE 100 PLYMOUTH VT 05056 DISQUALIFICATION 9/12/2016
SHACK, DANIEL RPH 2/4/1958 2 GRACEHILL COURT TITUSVILLE NJ 08560 SUSPENSION 9/20/2006
SHAH, JAYEN C. MD 5/15/1952 MEADOWLANDS PARKWAY SECAUCUS NJ 07096 DISQUALIFICATION 7/26/1996
SHAKARJIAN, CARNIG C. DPM 5/9/1962 1720007743 99 KINDERKAMACK RD. EMERSON NJ 07630 DEBARMENT 6/25/2013
SHARIF, MUDASSAR MD 3/27/1970 1366509903 308 MOUNTAIN ROAD BASKING RIDGE NJ 07920 DEBARMENT 12/16/2015
SHARMA, RAVINDER MD 2/18/1953 1306947999 3 MARTIN COURT MARTINSVILLE NJ 08836 DEBARMENT 1/22/2016
SHARMA, YOGENDRA P. OD 8/1/1944 17 VAHLSING WAY ROBBINSVILLE NJ 08691 DEBARMENT 2/28/2000
SHAROW, RALPH DMD 11/19/1945 1679670038 PO BOX 1000- CAMP FORT DIX NJ 08640 SUSPENSION 7/20/2003
SHEA, ANN M. RN 12/28/1973 706-08 ZLOTKIN CIRCLE FREEHOLD NJ 07728 SUSPENSION 10/18/2001
SHEIKH, IMTIAZ A. MD 2/20/1945 1008 BRAINARD PLACE BRIELLE NJ 08730 DISQUALIFICATION 12/1/1998
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
118
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SHEIKH, MOHAMMAD 7/9/1953 59-07 71ST AVENUE RIDGEWOOD NY 11385 DEBARMENT 10/20/2003
SHEIKH, NAFEESA 3/11/1957 516 BLOOMFIELD AVENUE NUTLEY NJ 07110 SUSPENSION 11/20/2003
SHERANI, TAHIR S. 5/7/1965 215 N. WYOMING STREET S. ORANGE NJ 07079 DISQUALIFICATION 2/7/2000
SHERMAN, HENRY M. MD 4/20/1942 1922334457 141 S. HARRISON STREET EAST ORANGE NJ 07018 DISQUALIFICATION 2/5/1997 12/14/2011
SHIELDS, HEATHER LPN 5/2/1973 100 ROLLING ACRES SLIPPERY ROCK PA 16057 DISQUALIFICATION 11/20/2015
SHIPMAN, BRYAN LEE 2/9/1973 1210 CHERSONESE ROUND MOUNT PLEASANT SC 29464 DISQUALIFICATION 3/20/2012
SHKLOVER, TOBIAS MD 5/14/1955 2611 W. 2ND STREET BROOKLYN NY 11223 SUSPENSION 9/20/2007
SHMIDMAN-HOROWITZ,
MIRIAM
5/8/1930 8215 ABINGDON RD. KEW GARDENS NY 11478 DISQUALIFICATION
SHROPE, CATHY L. 5/30/1967 175 COUNTY ROUTE 519 S. BELVIDERE NJ 07823 DISQUALIFICATION 7/22/2002
SHROUT, WILLIAM 3/22/1960 PO BOX 280 FAIRTON NJ 08320 SUSPENSION 9/20/2001
SHUSTER, LARRY B. RPH 1/2/1953 3136 GUILFORD STREET PHILADELPHIA PA 19152 SUSPENSION 3/9/2008 6/26/2017
SIAM, NABIL A. MD 67 HIGHWAY 37, PO BOX 193 TOMS RIVER NJ 08754 DEBARMENT 12/1/1999
SIBERT, SCOTT L. MD 43 WOODLAND AVENUE WOODBURY NJ 08096 DISQUALIFICATION 11/15/1985 DECEASED
SIDDIQUI, AFTAB A. MD 12/25/1932 1073527545 504 LIVINGSTON STREET NORWOOD NJ 07648 SUSPENSION 6/19/1998
SIDDIQUI, NURUL HASAN 4/19/1948 4912 BERGENLINE AVENUE WEST NEW YORK NJ 07093 DISQUALIFICATION 1/12/1996
SIDDIQUI, SHAKIR H. 5/14/1947 619 SCHUYLER AVENUE KEARNY NJ 07032 SUSPENSION 3/10/1998
SIDDIQUI, SHOAIB H. 6/25/1953 9 TOWER DRIVE EAST HANOVER NJ 07936 SUSPENSION 7/19/2001
SIEGEL, JONATHAN B. DPM 11/30/1959 4772 HIGHWAY 9 SOUTH HOWELL NJ 07731 DISQUALIFICATION 9/11/2000
SIGLE, EDWARD 10/2/1925 CRANBURY SOUTH RIVER RD. MONROE TWP. NJ 08831 DISQUALIFICATION 5/29/2007
SILMAN, ALEX DDS 4/7/1975 1629319751 3 CLARK PLACE MARLBORO NJ 07746 SUSPENSION 10/22/2010 1/5/2018
SILVA, SANDY COUNSEL
OR
2208 HILLCREST AVENUE PENNSAUKEN NJ 08110 SUSPENSION 4/29/2003
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
119
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SILVERHARDT, STEPHEN DDS 1881821403 1436 MARSHALL LANE MEADOWBROOK PA 19046 DISQUALIFICATION 2/16/1988
SILVERMAN, HAROLD 529 BROAD STREET NEWARK NJ 07102 DISQUALIFICATION
SIMMONS, SHAMEKIA RIDGE AVENUE ASBURY PARK NJ 07712 SUSPENSION 8/21/2008
SIMONE, RENEE CRIVELLO RPH 7/1/1977 403 SCOTT COURT UNION NJ 07083 SUSPENSION 10/22/2010
SIMONETH, A'DAYJA CHHA 6/14/1995 711 CEDAR STREET LAKEHURST NJ 08753 DISQUALIFICATION 4/18/2017
SINGER-ANDREINI
PHARMACY
5532 BERGENLINE AVENUE WEST NEW YORK NJ 07093 SUSPENSION 7/23/1998
SINGH, MANJIT MD 4/19/1943 21 LEHMAN STREET MAHWAH NJ 07430 SUSPENSION 2/24/1998
SINGH, MANJIT MD 4/19/1943 12 HARRISON MOUNT LAKE
RD
RINGWOOD NJ 07456 SUSPENSION 11/24/2007
SINGH, SAGGOO MD 3/19/1947 485 S. DOBSON RD., STE. 202 CHANDLER AZ 85224 SUSPENSION 11/20/1995
SINGH, SURINDER MD 4/2/1951 288 SUMMIT AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 7/23/2007
SINGLETON, RUSSELL DMD 5/28/1962 1912166133 401 BROADWAY CAMDEN NJ 08103 DISQUALIFICATION 8/9/2014 1/10/2018
SINGLETON, WANDRA LPN 6/12/1970 86 MELROSE AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 6/5/2017
SINHA, BINOD P. MD 7/26/1951 1932201662 3 HELENE AVENUE EDISON NJ 08820 DISQUALIFICATION 3/3/2017 PERMANENT
SINHA, BINOD P. MD 7/26/1951 1932201662 3 HELENE AVENUE EDISON NJ 08820 DISQUALIFICATION 12/6/2017 PERMANENT
SINVANY-NUBEL, AVIVA RN/APN 683 DONALD DRIVE NORTH BRIDGEWATER NJ 08807 SUSPENSION 10/20/2005
SIRIPURAPU, PADMA MD 5/12/1967 1710061056 201 LYONS AVENUE NEWARK NJ 07112 SUSPENSION 2/15/2012
SIRIPURAPU, PADMA MD 5/12/1967 1710061056 1 SCENIC HILLS COURT BELLE MEAD NJ 08502 DISQUALIFICATION 12/30/2014
SIROTA, ALEKSANDR 6/1/1970 PO BOX 2000 LEWISBURG PA 17837 DISQUALIFICATION 8/19/2010
SISON, JOSEPH MD 6/19/1957 1730110149 41 BROWNSTON WAY STE
218
ENGLEWOOD NJ 07631 SUSPENSION 8/2/2011
SIVAKANTHA,
SIVAGNANALIN
PSYCH 11/14/1964 1114080165 PO BOX 5503 SOMERSET NJ 08875 DISQUALIFICATION 9/20/2011
SKAGGS, MATTHEW A. 5/31/1972 2127 QUAETHEM DRIVE CHESTERFIELD MO 63005 DISQUALIFICATION 1/20/2012
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
120
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SKURATON, JEFFREY RPH 9/26/1943 WINGED FOOT DRIVE LIVINGSTON NJ 07039 SUSPENSION 6/19/2008
SLAKIE, CHRISTINE RN 6/27/1961 103 EDGE LANE WILLINGBORO NJ 08046 SUSPENSION 9/19/2003
SLATER, BARBARA A. LPN 7/28/1956 7 POINT RD. TOMS RIVER NJ 08753 SUSPENSION 10/18/2001
SLOAN, DEBRA 8/16/1954 31 SCHAAF RD. BLOOMSBURY NJ 08804 DEBARMENT 8/12/2012
SLOTNICK, SINO 1556 RIVER RD. TEANECK NJ 07666 DISQUALIFICATION 6/1/1993
SLOVER, SHAYLA 12/15/1958 NORTH MAPLE AVENUE MARLTON NJ 08053 SUSPENSION 6/4/2007
SMITH III, RUSSELL P. LPN 7/23/1955 33 ORCHARD AVENUE PENNINGTON NJ 08534 SUSPENSION 4/19/2007
SMITH III, RUSSELL P. LPN 7/23/1955 714 S. PENNSYLVANIA
AVENUE
MORRISVILLE PA 19067 DISQUALIFICATION 6/22/2007
SMITH, ALPHONSO MD 2/17/1938 421 WESTWOOD DRIVE #U WOODBURY NJ 08096 SUSPENSION 7/31/2002
SMITH, CHARLES M. 11/5/1988 1825 67TH AVENUE PHILADELPHIA PA 19126 DISQUALIFICATION 11/20/2015
SMITH, DWAYNE 1/1/1965 12-14 ELM STREET, APT. 6 MONTCLAIR NJ 07042 DISQUALIFICATION 9/23/2007
SMITH, JENNIFER LYNN 11/19/1979 428 GLENWOOD AVENUE WILLIAMSPORT PA 17701 DISQUALIFICATION 11/20/2015
SMITH, LAKESIA CHHA 5/4/1983 2030 RIVERSIDE DRIVE, APT.
10B
TRENTON NJ 08618 DISQUALIFICATION 2/20/2017
SMITH, LARRY 9/9/1960 183 SOUTH HIGHLAND
AVENUE, APT. 1
YORK PA 17404 DISQUALIFICATION 11/20/2015
SMITH, LAURA LPN 10/5/1959 1051 OLD FREEHOLD RD. TOMS RIVER NJ 08753 SUSPENSION 10/18/2007
SMITH, MARK RPH 3/21/1977 1510 OCEAN PARKWAY #18F BROOKLYN NY 11230 DEBARMENT 1/27/2017
SMITH, TAMMY CHHA 7/16/1980 203 LAKEVIEW BOULEVARD BROWNS MILLS NJ 08015 DISQUALIFICATION 2/8/2017
SMITH, WILLIAM 6/3/1931 RT 1 35 WHITE TAIL RD. SAN MARCOS TX 78666 DISQUALIFICATION
SMITH-DORSEY, JULIA RN 12/2/1969 37 WINFIELD DRIVE PARSIPPANY NJ 07054 DEBARMENT 8/2/2017
SMOLER, JOSEPH M. MD 158 HAMILTON AVENUE PASSAIC NJ 07055 DISQUALIFICATION 6/1/1993
SMOLIN, STEVE RPH 6/14/1949 1124184619 228 KINGS HIGHWAY BROOKLYN NY 11223 DISQUALIFICATION 9/7/2001
SMUTEK, MICHELLE M. LPN 12/29/1968 2115 FLORENCE AVENUE HAZLET NJ 07735 DEBARMENT 10/20/2002
SNELL, PHILIP MD 6/12/1915 217 PAULISON AVENUE PASSAIC NJ 07055 DISQUALIFICATION 6/1/1993
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
121
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SODANO, MICHAEL J. 9/10/1949 708 FOREPEAK AVENUE BEACHWOOD NJ 08722 DISQUALIFICATION 6/1/1993
SODANO, MICHAEL J. 9/10/1949 708 FOREPEAK AVENUE BEACHWOOD NJ 08722 SUSPENSION 1/6/1999
SOHN, YOUNG PSYCH 12/13/1932 63 CARLOUGH RD. U. SADDLE RIVER NJ 07458 SUSPENSION 6/20/2000
SOKHA, BORIS 7/26/1954 FCI FORT DIX FORT DIX NJ 08640 SUSPENSION 5/20/2009
SOLARZ, LAUREN 7/1/1955 1133 THACKERY CIRCLE VOORHEES NJ 08043 SUSPENSION 7/19/1999
SOLBERG, BYRNE MD 6/19/1953 1710996871 103 FOXHALL LANE NARBERTH PA 19072 DISQUALIFICATION 11/20/2015
SOLIMANDO, LISA LPN 5/17/1972 41 LONG VALLEY ROAD LODI NJ 07644 DISQUALIFICATION 3/28/2017
SOLOMON, JENNIFER 10/22/1969 142 BROAD STREET NEWARK NJ 07104 DISQUALIFICATION 6/25/2002
SOLOMON, MARCUS 7/2/1966 142 BROAD STREET NEWARK NJ 07104 DISQUALIFICATION 6/25/2002
SOMERSET, WILLARD RPH 1123 BROAD STREET NEWARK NJ 07114 DISQUALIFICATION 1/1/1988
SONG, KI I. MD 4/20/1941 1720138936 62 COTTAGE STREET JERSEY CITY NJ 07306 SUSPENSION 4/7/2011
SONG, YO-JUN MD 8/10/1945 1982657540 1857 DIAMOND HEALTH
DRIVE
CASTLE ROCK CO 80104 DISQUALIFICATION 8/28/2017 PERMANENT
SONG, YOUNG 37 DEANNA DRIVE EAST HANOVER NJ 07936 DISQUALIFICATION 7/19/2010 7/19/2015
SONI, HARDIK MD 4/20/1975 1750498028 90 BEAUVOIR AVENUE SUMMIT NJ 07901 DISQUALIFICATION 7/22/2017
SONZA, PATRICIO A. MD 3/17/1945 1316974850 8 CONSTITUTION WAY FLEMINGTON NJ 08822 SUSPENSION 11/20/2010
SORBELLO, TANYA J. LPN 5/20/1969 460 NEW STREET EAST GLASSBORO NJ 08028 SUSPENSION 2/19/2004
SORONGON, MARCELINO MD 4/26/1941 192 SURREY COURT RAMSEY NJ 07446 SUSPENSION 5/18/2000
SOSTOWSKI, RICHARD M. MD 10/1/1947 1003038951 250-1 BROOK HOLLOW LANE BERNARDSVILLE NJ 07924 DEBARMENT 11/20/2014 5/16/2016
SOTO, GREGORIO 153 LEWIS STREET PERTH AMBOY NJ 08861 DEBARMENT 3/18/2015
SOUTHERN MEDICAL &
SURGICAL
2230 S. CROSKEY STREET PHILADELPHIA PA 19145 DISQUALIFICATION 4/19/1992
SOUTHERN OCEAN
PEDIATRICS AND FAMILY
MEDICINE
1346664893 1100 ROUTE 72 WEST, SUITE
304
MANAHAWKIN NJ 08050 SUSPENSION 1/27/2017 4/27/2017
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
122
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
SOYFER, ALEXANDER 7/31/1955 655 AMBOY AVENUE WOODBRIDGE NJ 07095 DISQUALIFICATION 5/21/2002
SOYFER, ALEXANDER 7/31/1955 104 MAPLE HILL DRIVE WOODBRIDGE NJ 07095 SUSPENSION 6/20/2001
SPADARO, BREKKE AKA
BREKKE BEST
RN 6/10/1981 35 WOODROW AVENUE FRANKLIN LAKES NH 03235 DISQUALIFICATION 2/20/2018
SPAIN, ANTHONY B. DMD 5/12/1961 1451316098 113 CRESCENT AVENUE PLAINFIELD NJ 07060 DEBARMENT 5/28/2002
SPANIER, CYNTHIA PSYCH 11/16/1958 530 BROOKDALE DRIVE PITTSBURGH PA 15215 DISQUALIFICATION 11/20/2015
SPANO, ANTHONY THERAPIS
T
6/30/1949 176 EVERGREEN STREET HILLSDALE NJ 07642 SUSPENSION 11/20/2003
SPAVLIK, LAURIE R. 8/3/1968 200 EAST GRANT AVENUE SOMERDALE NJ 08083 SUSPENSION 4/19/2001
SPECIALTY CLINICAL
LABORATORY
299 ACADEMY STREET JERSEY CITY NJ 07306 DISQUALIFICATION 12/1/1998
SPECTOR, IOSIF G. MD 54 INDIAN DRIVE WOODCLIFF LAKE NJ 07675 SUSPENSION 9/20/2000
SPEDALIERE, CARMINE MD 10/27/1923 1601 KENNEDY BLVD. NORTH BERGEN NJ 07407 DISQUALIFICATION 7/19/1999
SPIGNER, AKOSUA RPH 10/25/1960 941 LINCOLN AVENUE GLEN ROCK NJ 07452 DEBARMENT 5/15/2014
SPINAPOLICE, JOSEPH DO 4/7/1944 1063678670 811 WASHINGTON STREET PARLIN NJ 08859 DISQUALIFICATION 4/1/2016 PERMANENT
SPINELLI, PAULA CHHA 4/7/1972 94 FAIR STREET HACKENSACK NJ 07601 DISQUALIFICATION 9/19/2017
SPIVEY, DEBRA RN 9/30/1983 644 STUYVESANT AVENUE,
APT. 2
TRENTON NJ 08611 DISQUALIFICATION 6/28/2017
SPLITTER, SAMUEL R. MD 4/24/1914 1742 MARYLAND AVENUE CAPE MAY NJ 08204 DISQUALIFICATION 5/4/1998
SPYRIDON-MARKER,
KAREN
25 ELKINTON RD. ALLOWAY NJ 08001 DISQUALIFICATION 10/20/2002
ST PETER, LISA 2/12/1964 PO BOX 2000 BRUCETON MILLS WV 26525 DEBARMENT 11/17/2008
STANCH, JAMES M. PSYCH 10/13/1952 160 S. LAKESHORE DRIVE MANAHAWKIN NJ 08050 SUSPENSION 5/3/2006
STANCH, JAMES M. PSYCH 10/13/1952 FCI PO BOX 350 BEAVER WV 25813 SUSPENSION 11/20/2008
STANKO-STRACK, MARY
ELIZABETH
RN 8/31/1962 1348 MILLENNIUM COURT TOMS RIVER NJ 08753 DISQUALIFICATION 5/20/2010
STANLEY, JAMES R. 4/7/1959 PO BOX 38, FCI FORT DIX NJ 08640 SUSPENSION 12/20/2001
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
123
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
STANTON JR., FRANCIS X. MD 7/27/1954 1327 CAMINITO BATEA LA JOLLA CA 92037 DEBARMENT 10/18/2001
STARKMAN, MOISHE MD 7/16/1959 1871609149 2206 YELLOWSTONE ROAD CINNAMINSON NJ 08077 DISQUALIFICATION 10/11/2017 PERMANENT
STATLINE AMBULANCE &
MEDI-COACH
PO BOX 2100 WEST PATERSON NJ 07424 DISQUALIFICATION 1/15/1987
STAVCO, INC. 300 MAIN STREET AVON NJ 07717 DISQUALIFICATION 1/11/2005
STAVITSKI, MICHAEL RPH 5/4/1963 419 FAWNS RUN MORGANVILLE NJ 07751 DISQUALIFICATION 7/12/2002
STEEL, BURTON B. MD 1 ROUND HILL RD. WASHINGTONVILLE NY 10992 DISQUALIFICATION 6/14/1984
STEFANELLI, DANETTE DC 7/5/1967 1831245760 91 EAGLE ROCK AVENUE, APT.
A
ROSELAND NJ 07068 DISQUALIFICATION 10/28/2015
STEFANELLI, LEONARD RPH 8/21/1964 1285958645 11 DOGWOOD LANE EAST HANOVER NJ 07936 DISQUALIFICATION 11/14/2014 PERMANENT
STEFANELLI, LEONARD RPH 8/21/1964 1285958645 11 DOGWOOD LANE EAST HANOVER NJ 07936 DISQUALIFICATION 3/29/2017 PERMANENT
STEFANELLI, LEONARD RPH 8/21/1964 1285958645 MDC BROOKLYN 80 29TH
STREET
BROOKLYN NY 11232 DISQUALIFICATION 7/20/2015 PERMANENT
STEFFEN, H. PAUL 10/16/1947 4305 APPLE LANE PAULSBORO NJ 08066 SUSPENSION 9/20/2001
STEFFENS, PAUL G. 8/16/1953 1778 CALICO LANE TOMS RIVER NJ 08753 DEBARMENT 4/23/2003
STEIG, HERMAN S. DPM 8/27/1951 827 CHARNWOOD DRIVE FRANKLIN LAKES NJ 07417 DISQUALIFICATION 10/19/1999
STEIN, MARSHA J. MD 5/3/1956 1831191022 5936 HOWE STREET PITTSBURGH PA 15232 DEBARMENT 3/27/2015
STEIN, MICHAEL P. MD 1/29/1949 1174607782 400 RT. 10 WEST RANDOLPH NJ 07869 DISQUALIFICATION 10/5/1999
STEIN, MICHAEL P. MD 1/29/1949 1174607782 FMC LEXINGTON LEXINGTON KY 40512 DEBARMENT 8/20/2012
STEINBRECHER, DEBRA RN 9/3/1964 2302 WIMBLEDON WAY BLACKWOOD NJ 08012 DISQUALIFICATION 2/26/2010
STEINMAN, ARTHUR C. DO 10/15/1946 301 MADISON AVENUE LAKEWOOD NJ 08701 DISQUALIFICATION 11/11/1991
STEPASCENKO, SVETLANA CHHA 10/23/1950 100 STONE HILL RD., APT. D-
12
SPRINGFIELD NJ 07081 DEBARMENT 1/22/2016
STEPHENS, ALICIA T. PHARM
TECH
10/9/1980 5322 RIVERSIDE STATION BL SECAUCUS NJ 07094 SUSPENSION 11/20/2010
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
124
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
STEPHENS, JEFFREY 5/21/1955 411 JAROB COURT POINT PLEASANT NJ 08742 SUSPENSION 3/20/2007
STEVENS, FELICIA LPN 5/30/1987 56 WERT AVENUE HAMILTON NJ 08610 DEBARMENT 3/15/2018
STEVENS, TRACY M. RN 8/13/1960 501 S. BERLIN AVENUE EGG HARBOR CITY NJ 08215 SUSPENSION 4/20/2003
STEWART, SHANTE CHHA 12/12/1971 16B WHITE HORSE PIKE WATERFORD
WORKS
NJ 08089 DISQUALIFICATION 1/22/2018
STIER, ERIC G. DO 891 OLENTANGY RD. FRANKLIN LAKES NJ 07417 DEBARMENT 3/6/2000
STILL, DAWN AKA DAWN
ATKINS
CHHA 9/17/1988 697 EVERETT STREET CAMDEN NJ 08104 DISQUALIFICATION 3/6/2018
STILLWAGON-AHLERS,
DAWN
COUNSEL
OR
11/15/1969 SUNSET LAKE RD. HARDWICK NJ 07825 SUSPENSION 10/20/2008
STILWELL, MELISSA CHHA 419 CATHERINE STREET SOMERVILLE NJ 08876 SUSPENSION 2/19/2004
STIMMEL-KEAY, LINDA 5 DRAYTON PLACE WAYNE NJ 07470 DEBARMENT 1/1/2014
STOKES, RONALD L. CHHA 11/14/1961 124 6TH AVENUE LONG BRANCH NJ 07740 SUSPENSION 9/19/2003
STOKLEY, TWANDA CHHA 7/26/1961 1372 SPRINGFIELD AVENUE IRVINGTON NJ 07111 DISQUALIFICATION 4/18/2017
STONE, MARY E. RN 2/19/1954 132 CORBIN COURT LAKEWOOD NJ 08701 SUSPENSION 10/19/2006
STOUDEN, ELENA DDS 1/27/1964 1619199882 EAST 83RD ST. NEW YORK NY 10028 SUSPENSION 6/19/2008
STOVEKEN, ANDREW 2/4/1950 27-11 RAVENS CREST DRIVE PLAINSBORO NJ 08536 DEBARMENT 5/15/2005
STRASHNOV, ALEKSANDR CHHA 7/19/1964 4816 GONIAK DRIVE PARLIN NJ 08859 DISQUALIFICATION 5/18/2017
STRASSMAN, ALLAN 5/25/1929 5 ROANOKE AVENUE ROCKAWAY NJ 07866 SUSPENSION 11/16/1998
STRASSMAN, ALLAN 5/25/1929 5 ROANOKE AVENUE ROCKAWAY NJ 07886 DISQUALIFICATION 12/1/1998
STRASSMAN, CAROL 120 S. 20 TH STREET IRVINGTON NJ 07111 SUSPENSION 3/16/1995
STRASSMAN, WAYNE 11/17/1957 2 NEW COUNTRY RD. SECAUCUS NJ 07094 DISQUALIFICATION 3/5/1998
STRINE JR., WALTER M. 173 ROSE VALLEY RD. MEDIA PA 19063 SUSPENSION 7/11/2001
STROBECK, JOHN MD 9/12/1946 1215936299 12 PINE TREE DRIVE SADDLE RIVER NJ 07458 SUSPENSION 6/6/2016
STROGOV, EMILIA DPM 5/5/1945 1225115801 COOPER RD. SCOTCH PLAINS NJ 07076 DISQUALIFICATION 3/24/1995
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
125
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
STRUM, MORTON W. 1360 ARBORDALE RD. PHILADELPHIA PA 19151 DISQUALIFICATION
SUGGS, SHANTAYA CHHA 10/8/1989 115 HALSTED STREET EAST ORANGE NJ 07018 DEBARMENT 12/26/2017
SUH, JEFFREY ACCUPU
NCTURIST
10/19/1959 1336523497 FORT DIX FCI, PO BOX 2000 JOINT BASE MDL. NJ 08640 DISQUALIFICATION 9/23/2016
SULAIMON, TANFEEK CHHA 10/12/1983 321 GARFIELD AVENUE TRENTON NJ 08629 DISQUALIFICATION 1/22/2018
SULLIVAN, JOHN M. 6/3/1948 PO BOX 2000 LEWISBURG PA 17837 DISQUALIFICATION 7/30/1998
SULLIVAN, NOELLE CHHA 10/19/1986 H-9 HUNTER HILLS
APARTEMENTS
FLEMINGTON NJ 08822 DISQUALIFICATION 7/14/2017
SUN, KENNETH MD 4/19/1961 1881693109 382 EPPS STREET WIND GAP PA 18091 DISQUALIFICATION 3/3/2017
SUN, KENNETH MD 4/19/1961 1881693109 15 MOUNTAIN TOP ROAD WIND GAP PA 18091 DISQUALIFICATION 2/20/2018
SUNG, KYUNG EUN DDS 9/9/1977 1215122205 428 RUSSELL AVENUE EDGEWATER NJ 07020 DEBARMENT 9/20/2012
SURECK, MORRIS M. OD 4/20/1922 12 NORTH 4TH AVENUE HIGHLAND PARK NJ 08904 DISQUALIFICATION 7/5/1988
SUSSMAN, GERALD DO 9/3/1937 6 EAST FIRST AVENUE RUNNEMEDE NJ 08708 SUSPENSION 5/20/1998
SUTTON, DEJA CHHA 1/26/1992 802 MAIN STREET 1-3 TOMS RIVER NJ 08753 DISQUALIFICATION 5/2/2017
SVERDLOV, GREGORY 11/20/1957 269 SHEFFIELD ST. MOUNTAINSIDE NJ 07092 DISQUALIFICATION 8/7/1998
SWAIN, CHERIE CHHA 10/6/1968 2217 NORTH 43RD STREET PENNSAUKEN NJ 08110 DEBARMENT 3/6/2018
SWARAY, MAYANGBE CHHA 5/12/1985 314 MORRIS AVENUE NEWARK NJ 07103 DISQUALIFICATION 4/14/2014
SWEITZER, JANET 8/31/1930 950 ORCHARD AVENUE, LOT
28
CAMP HILL PA 17011 DISQUALIFICATION 11/20/2015
SZARSZEWSKI, MARK A. RPH 6 MARIGOLD CT. EDISON NJ 08820 SUSPENSION 9/20/2005
SZTYBEL, ELVIRA 35 PEACHTREE RD. OAKHURST NJ 07755 DISQUALIFICATION 7/18/2001
T & N PHARMACEUTICAL
CO.
90 WASHINGTON STREET EAST ORANGE NJ 07017 SUSPENSION 9/22/2000
TABOTABO, ARMANDO MD 6/18/1940 12 WEST FRONT STREET KEYPORT NJ 07735 DEBARMENT 4/12/2001
TADROS, AMIR RPH 8/22/1977 6 ALEXANDER CT. JERSEY CITY NJ 07305 DISQUALIFICATION 6/30/2010 2/5/2018
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
126
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
TADROS, AMIR RPH 8/22/1977 6 ALEXANDER COURT, APT. 6N JERSEY CITY NJ 07305 DEBARMENT 12/20/2012 2/5/2018
TAFT, ARNOLD 333 NORTH BROAD STREET ELIZABETH NJ 07028 SUSPENSION 7/21/1997
TAMEKA FORD CHHA 11/27/1970 600 ELM STREET CAMDEN NJ 08102 DISQUALIFICATION 1/31/2017
TANDLER, ROBERT OD 8/21/1950 1104812924 792 GREEN LANE UNION NJ 07013 DEBARMENT 4/29/2016 10/27/2017
TAPPER, FREDERIC S. DO 7/8/1951 39 BROOKSIDE DRIVE WARREN NJ 07059 DEBARMENT 8/21/2000
TAPPIA, YEALESEH CHHA 7/15/1994 941 IVORIE COURT BURLINGTON NJ 08016 DISQUALIFICATION 2/8/2017
TARA, HAROLD H. MD 10/17/1929 48 BROOKWOOD DRIVE WAYNE NJ 07470 DISQUALIFICATION 6/1/1993 DECEASED
TARANTO, SHERRY L. DENTAL
HYGIENIS
T
26 COOMES STREET NORWICH NY 13815 DEBARMENT 12/2/2012
TARASEVICH, LISA LPN 4/20/1961 206 LAKEHURST AVENUE,
APT. B
NATIONAL PARK NJ 08063 SUSPENSION 9/19/2002
TARKAS, SURBHI 8 CARLTON COURT EAST BRUNSWICK NJ 08816 SUSPENSION 6/23/2004
TARVER, JOLYCE CHHA 5/16/1989 15 HEATHWOOD AVENUE JACKSON NJ 08527 DISQUALIFICATION 8/22/2017
TASCA, ANTHONY J. RN 11 SAWGRASS COURT BLACKWOOD NJ 08012 SUSPENSION 10/20/2003
TAUSCHEK, JENNIFER L. CHHA 3/1/1978 154 MAPLE AVENUE TUCKERTON NJ 08087 SUSPENSION 9/20/2005
TAVERA, CESAR 2/25/1964 812 LONGWOOD AVENUE CHERRY HILL NJ 08002 SUSPENSION 9/11/2017
TAVERA, MARIA 2/25/1964 812 LONGWOOD AVENUE CHERRY HILL NJ 08002 SUSPENSION 9/11/2017
TAYLOR, BARBARA AKA
MONDELO, BARBARA
12/14/1965 363 KENTWOOD BLVD BRICK NJ 08724 DEBARMENT 10/24/2008
TAYLOR, JANICE CHHA 3/14/1953 66 DUFFIELD DRIVE SOUTH ORANGE NJ 07079 DISQUALIFICATION 2/8/2017
TAYLOR, STEVEN RN 7/19/1965 25 SYLVAN LANE WILLINGBORO NJ 08046 DISQUALIFICATION 7/20/2017
TAYLOR, THOMAS MD 7/19/1943 1356454292 1402 CASTLE COURT HOUSTON TX 77006 DISQUALIFICATION 5/1/2017
TAYLOR, TIANN RN 3/22/1967 PO BOX 4004 CLINTON NJ 08809 DEBARMENT 6/20/2006
TELANG, FRANK W. MD 12/5/1955 1497798706 1030 N. KINGS HIGHWAY CHERRY HILL NJ 08034 DEBARMENT 8/28/2014
TELANG, FRANK W. MD 12/5/1955 1497798706 1030 W. KINGS HIGHWAY CHERRY HILL NJ 08034 DISQUALIFICATION 12/5/1997
For verifications
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
127
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
TELGHEDER, MARGARET 7/24/1954 75 SPRING VALLEY RD MONTVALE NJ 07645 SUSPENSION 6/20/2002
TENSLEY, SHENEQUA 10/11/1973 364 EAST MOORE STREET NORRISTOWN PA 19401 DISQUALIFICATION 11/20/2015
TERCHIO, GAETANO FRED 104 E PALISADE BLVD PALISADE PARK NJ 07650 DISQUALIFICATION
TERPENNING, CLARENCE PHD 303 CARTER RD. PRINCETON NJ 08540 DISQUALIFICATION 11/19/1986
TERWILLIGER, KRISTINE RN 7/8/1976 1 DUANE STREET JAMESBURG NJ 08831 DISQUALIFICATION 10/25/2016
TESHNER, TERRI PHARM
TECH
4/1/1963 300 NORTH BLACK HORSE
PIKE, APT. B-1
RUNNEMEDE NJ 08078 DISQUALIFICATION 12/26/2016
THAMES, DOUGLAS A. MD 7/22/1964 218 WEST AVENUE PITMAN NJ 08071 SUSPENSION 3/20/2001
THEUNE, CHRISTOPHER DO 12/30/1966 1639141583 5678 BERKSHIRE VALLEY RD. OAK RIDGE NJ 07438 DEBARMENT 10/15/2012 10/15/2015
THEUNE, CHRISTOPHER DO 12/30/1966 1639141583 32 WARNER ROAD NEWTON NJ 07860 DISQUALIFICATION 6/5/2017
THOMAS, ERIC MD 1/16/1967 1528378072 8460 EVERGREEN DRIVE HELENA MT 59602 DISQUALIFICATION 2/22/2018 PERMANENT
THOMAS, GWENDOLYN LPN 5/22/1941 48 ROANOKE STREET WOODBRIDGE NJ 07095 DISQUALIFICATION 3/3/2017
THOMAS, LISA M. CHHA 8/16/1968 402 UNION AV, APT. #3 IRVINGTON NJ 07111 SUSPENSION 4/20/1999
THOMAS-MCNAIR, GLORIA 6/17/1939 590 BELLVUE AVENUE TRENTON NJ 08618 DISQUALIFICATION 12/21/1999
THOMPSON, ARTHUR V. 855 THORNHILL COURT LAKEWOOD NJ 08701 SUSPENSION 1/19/2010
THOMPSON, DAPHNE CNA 2247 HIGH STREET ORANGE NJ 07050 DEBARMENT 3/29/2002
THOMPSON, DEBORAH A. LPN 1/29/1952 1006 COLLINGS AVENUE CAMDEN NJ 08102 SUSPENSION 6/19/2003
THOMPSON, KENNETH H. EMT 12/6/1967 408 SADDLE COURT FLEMINGTON NJ 08822 DISQUALIFICATION 4/28/2003
THOMPSON, LORNA MD 6/5/1957 20 OAK POINT DRIVE SO. BAYVILLE NY 11709 SUSPENSION 8/20/2000
THOMPSON, SHAKEEMA CHHA 1/26/1982 1034 ANNA STREET ELIZABETH NJ 07201 DISQUALIFICATION 2/26/2018
THOOMPALLY, SRINATH RPH 7/30/1967 1255381443 18 LAFAYETTE CIRCLE TOTOWA NJ 07512 DEBARMENT 12/5/2013 12/17/2015
For verifications
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
128
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
THOTTEMPUDI, VENKATA 11/4/1967 13 VINCENT BEHAN BLVD EDISON NJ 08837 DISQUALIFICATION 4/12/2012
THOTTEMPUDI, VENKATA 11/4/1967 13 VINCENT BEHAN BLVD EDISON NJ 08837 DISQUALIFICATION 9/9/2013
TICE, LINDSEY LPN 3/19/1982 20 PARVINS MILL RD. BRIDGETON NJ 08302 SUSPENSION 9/20/2005
TIDD, MILES LPN/RN 26 CORAL TREE CT. TRENTON NJ 08648 SUSPENSION 6/20/2005 1/9/2012
TISCORNIA, KIMBERLY RN 12/9/1972 18 TORNE MOUNTAIN RD. WEST MILFORD NJ 07480 SUSPENSION 6/20/2005
TOBACK, BARRY RPH 4/8/1952 1375 RIVER RD. EDGEWATER NJ 07020 SUSPENSION 6/19/2003
TOFANI, NANCY 8/3/1954 114 COUNTY RD. 513 PITTSTOWN NJ 08867 SUSPENSION 6/14/2000
TOMLIN, CANDICE PHARM
TECH
9/23/1980 1255517934 38-19 FAIRLAWN AVENUE FAIRLAWN NJ 07410 DISQUALIFICATION 9/9/2016
TOMLIN, TERESA L. DPM 8/16/1961 232 KRISTINE AVENUE MANAHAWKIN NJ 08050 SUSPENSION 3/5/2008
TOMPKINS, AMBER LPN 7/25/1990 17 LEHIGH ROAD PARLIN NJ 08859 DISQUALIFICATION 6/15/2018
TONG, DARLENE M. RPH 9/27/1971 108 LOWER LANDSDOWN RD. ANNANDALE NJ 08801 SUSPENSION 11/12/2009
TORIBIO, ANTHONY X-RAY
TECH
11 BYRON DRIVE LOPATCONG NJ 08865 SUSPENSION 9/28/2001
TORO, NORMARY CHHA 11/16/1989 1173 ATLANTIC AVENUE, APT.
B
CAMDEN NJ 08104 DISQUALIFICATION 2/8/2017
TORPPEY, JONI LPN 4/5/1959 28 CHURCH ROAD NEWTON NJ 07860 DISQUALIFICATION 6/5/2017
TORRES, FRANCES 437 STUYVESANT AVENUE
APT
IRVINGTON NJ 07111 DISQUALIFICATION 4/27/2007
TORRES, JAIME 9/13/1950 14TH STREET, U-25 VILLARICA BAYAMO PR 00959 SUSPENSION 6/7/2000
TORRES, MANUEL G. 5/18/1945 ST. 18 ATE, PRADERA TOA BAJA PR 00940 SUSPENSION 6/7/2000
TORRES, MILESTY CHHA 6/4/1982 407 NORTH 31ST STREET CAMDEN NJ 08105 DISQUALIFICATION 1/31/2017
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
129
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
TORRESS, KRISTINA CHHA 8/28/1991 53 STEGMAN STREET, APT. #4 JERSEY CITY NJ 07305 DISQUALIFICATION 1/24/2018
TOSCANO, SYLVIA 13 NORTHGATE WAY TOMS RIVER NJ 08753 DEBARMENT 8/12/2013
TOTH, TEREZIA M. MD 9 N 2ND AVENUE HIGHLAND PARK NJ 08904 DISQUALIFICATION 3/6/2006
TOUCH OF LIFE, LLC. CHELSEA AVENUE NEWARK NJ 07106 SUSPENSION 3/9/2008
TOUSSAINT, VALENTINA 240 WEST 104TH STREET NEW YORK NY 10025 DISQUALIFICATION 2/8/2006
TOY, SUSAN 12/20/1971 727 SUMMIT ROAD UNION NJ 07083 DISQUALIFICATION 2/9/2017
TRASTER, LAWRENCE 19 BRAEMAR DRIVE WAYNE NJ 07470 DISQUALIFICATION 9/21/1983
TRAVERSO, JOSEPH L. MD 2/21/1946 5 OLD SALEM RD. W. ORANGE NJ 07052 SUSPENSION 9/20/2005
TRAYNOR, PATRICK 6/22/1941 2314 WOODLAND RD. ABINGTON PA 19001 DEBARMENT 12/5/2003
TREGO-CAMPION, ANITA RPH 8/15/1960 136 S. FELLOWSHIP RD. MAPLE SHADE NJ 08052 SUSPENSION 10/20/2005
TREMO, GREGORY RPH 11/21/1966 13276 WHIPPINGHAM
PARKWAY
NEW CARROLTON VA 23314 SUSPENSION 11/20/2006
TRENTACOSTA, GREG S. DC 10/9/1971 1720293079 1565 RATZER RD. WAYNE NJ 07470 SUSPENSION 6/20/2005
TRINIDAD, TITO B. MD 9/2/1939 PO BOX 1000 #10912-068 LEWISBURG PA 17837 SUSPENSION 11/10/1996
TRIVEDI, AMRITLAL PHD 6/30/1928 20 CYPRESS RD. BURLINGTON NJ 08016 DISQUALIFICATION 5/2/1978
TROLLINGER, ROBERT J. MD 4/9/1926 212 ROUTE 541 NORTH MEDFORD NJ 08055 DEBARMENT 10/10/2001
TSAI, DAVID MD 11/1/1965 12 NORTH 7TH AVENUE MOUNT VERNON NY 10550 DEBARMENT 6/23/2000
TSIRKINA, NATALIA 5/21/1955 13675 PHILMONT AVENUE PHILADELPHIA PA 19116 DISQUALIFICATION 11/20/2015
TUCHMAN, ALAN P. DPM 10/2/1946 1851380851 WEST MAIN STREET FREEHOLD NJ 07728 SUSPENSION 4/21/2008 8/29/2011
TUCKER, APRIL CHHA 3/11/1981 193 BENNER AVENUE NEWARK NJ 07112 DISQUALIFICATION 7/14/2017
TUCKER, BURT A DDS 11/20/1937 530 BRICK BLVD BRICKTOWN NJ 08723 DISQUALIFICATION 12/31/1999 DECEASED
TUCKER, KAREN E. DPM 5/24/1965 1992052930 1 BERYNWOOD AVENUE MARLTON NJ 08053 SUSPENSION 7/20/2002 7/15/2016
TUCKER, SUZANNE RN 8/1/1964 127 GAYWOOD AVENUE COLONIA NJ 07067 SUSPENSION 5/20/2001
TULSANIA, NITAN 7/1/1955 40 BROOKSIDE RD. EDISON NJ 08817 DEBARMENT 4/27/2004
TUMAS, MARY DC 9/13/1953 537 FISK AVENUE BRIELLE NJ 08730 DISQUALIFICATION 7/28/2014
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
130
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
TUMIWA, ARNOLD RN 4/20/1984 44 CIRCLE PLACE LAKEWOOD NJ 08701 DISQUALIFICATION 5/2/2018
TUNG, MING C. DPM 10/15/1944 1043387608 MITCHELL AVENUE EAST BRUNSWICK NJ 08816 SUSPENSION 8/24/2007
TURTON, IAN LPN 7/6/1968 52 BAY SHORE DRIVE TOMS RIVER NJ 08753 DISQUALIFICATION 4/24/2018
TYER, DOUGLAS D. 175 1ST STREET, APT. 16L NEWARK NJ 07102 DISQUALIFICATION 11/22/2005
TYRELL, MARK N. RPH 1/11/1955 58 HAVERHILL AVENUE LITTLE FALLS NJ 07424 SUSPENSION 8/19/2004
UHLIG, CYNTHIA 7/26/1957 204 WYOMING STREET WESTFIELD NJ 07090 SUSPENSION 9/20/2006
UHUNMWANGHO,
OZIEGBE
CHHA 11/29/1996 818 SOUTH 18TH STREET NEWARK NJ 07108 DISQUALIFICATION 9/12/2017
UKO, BRIDGET CHHA 4/19/1956 47 HEMPSTEAD DRIVE SOMERSET NJ 08873 DISQUALIFICATION 7/14/2017 PERMANENT
UNION CITY DIAGNOSTIC
LAB
2201 BERGENLINE AVENUE UNION CITY NJ 07007 DEBARMENT 6/10/2001
UNITED DENTAL CENTER 35 WALLINGTON AVENUE WALLINGTON NJ 07057 SUSPENSION 9/18/2003
UNITED DIAGNOSTIC LAB,
INC.
100 CRAIG RD., SUITE 104 MANALAPAN NJ 07726 SUSPENSION 4/18/1997
UNITED PHARMACY 1347 SPRINGFIELD AVENUE IRVINGTON NJ 07111 DEBARMENT 7/30/2005
UNIVERSAL MEDICAL LAB. 43 MOONACHIE ROAD HACKENSACK NJ 07601 DISQUALIFICATION 5/10/1999
UNIVERSAL MEDICAL
TRANSPORTATION
845 BERGEN AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 6/14/1994
URVINA ESTRADA, GINA CHHA 5/18/1961 169 JACKSON STREET PASSAIC NJ 07055 DISQUALIFICATION 7/31/2017
US CLINICAL LABORATORY,
INC.
185 S. EUCLID STREET PASADENA CA 91101 DEBARMENT 4/22/1997
V.C. LABORATORY, INC. 9 COURTLAND AVENUE STATEN ISLAND NY 10301 DISQUALIFICATION 3/24/2003
VALDES JR., ALFREDO TNT
MEDICAL
10/27/1974 1780644427 135 HAZEL STREET, APT. 65 CLIFTON NJ 07011 DISQUALIFICATION 1/29/2018
VALENCIA, RAFAEL MD 4/28/1950 1518045525 146 LAKEVIEW DRIVE GIBBSBORO NJ 08026 DISQUALIFICATION 11/9/2017 PERMANENT
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
131
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
VALENZUELA, ROGER CHHA 11/4/1991 517 LINCOLN STREET UNION CITY NJ 07087 DISQUALIFICATION 2/8/2017
VALLEJOS, ANA CHHA 10/29/1975 943 NORTH BROAD STREET ELIZABETH NJ 07208 SUSPENSION 5/14/2007
VALMON, CAMILLE CHHA 10/18/1990 1106 SUMMER WIND DRIVE JONESBORO GA 30236 DISQUALIFICATION 2/8/2017
VALUE-RITE PHARMACY,
INC.
350 WEST MARKET STREET NEWARK NJ 07107 SUSPENSION 4/29/1977
VANDYK, TRICIA 8/24/1975 1412 ISABELLE COURT BRICK NJ 08724 DISQUALIFICATION 8/11/2012 8/10/2014
VANSCIVER, SUZANNE RN 10/4/1965 1187 NESHAMINY VALLEY
DRIVE
BENSALEM PA 19020 DISQUALIFICATION 6/28/2017
VARSOS, ARISTIDES G. MD 28 47 37TH ST. ASTORIA NY 11103 DISQUALIFICATION 2/24/1986
VASKO, OLGA 3 PARKWOOD DRIVE SOUTH AMBOY NJ 08879 DISQUALIFICATION 7/10/2003
VASOYA, PRAVIN MD 3/27/1967 1770665135 METROPOLITAN DETENTION
CTR. #41549-050
BROOKLYN NY 11232 DISQUALIFICATION 8/1/2009
VASSERMAN, ALEKSANDR PARAME
DIC
10/7/1983 851 RED LION RD., APT. E1 PHILADELPHIA PA 19115 DISQUALIFICATION 11/20/2015
VASSERMAN, IRINA 11/30/1962 851 RED LION RD., APT. E1 PHILADELPHIA PA 19115 DISQUALIFICATION 11/20/2015
VASTEY, GARDY DC 3/25/1970 1114148806 1144 USTLER ROAD APOPKA FL 32712 DISQUALIFICATION 6/28/2017
VASWANI, VIJAY MD 11/29/1968 1194785956 9 TYNMOUTH DRIVE LUMBERTON NJ 08048 DEBARMENT 2/15/2016
VECCHIONE, JOHN DDS 6/5/1968 1710926076 1 CAROL DRIVE ENGLEWOOD CLIFFS NJ 07632 DISQUALIFICATION 2/20/2017
VEGA, DEBORAH 9/30/1958 2409 BOOKER AVENUE UPPER CHICHESTER PA 19014 DISQUALIFICATION 11/20/2015
VELOSO, CESAR MD 2/16/1939 1104800333 532 AMSTERDAM AVENUE RIDGEWOOD NJ 07450 DISQUALIFICATION 6/20/2018
VENANZI, ENZO DO 9/29/1927 107 NORTH BROAD STREET WOODBURY NJ 08096 DISQUALIFICATION 9/9/1996
VENDETTI CLINICAL
LABORATORY, INC.
904D OAK TREE ROAD SOUTH PLAINFIELD NJ 07080 DEBARMENT 12/1/1999
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
132
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
VENKATRAM, PRABHAKAR MD 3305 VILLAGE DRIVE AVENEL NJ 07001 DEBARMENT 11/28/1998
VENTURA, MARIA CHHA 8/2/1946 135 BELMONT STREET, #204 JERSEY CITY NJ 07304 DISQUALIFICATION 8/22/2017
VERBARO, DENNIS DC 1/9/1951 1558426122 384 MAIN STREET CHESTER NJ 07930 DISQUALIFICATION 12/1/1998
VICENTI, CARMILLA C. MD 40-15 QUAIL RIDGE RD. PLAINSBORO NJ 08536 SUSPENSION 3/18/1999
VICIOSO, MARGARITA MD 4/9/1959 1922058932 7801 BUSTLETOWN AVENUE,
APT. 104
PHILADELPHIA PA 19152 DISQUALIFICATION 12/29/2015
VICTORY PHARMACY 1238 SPRINGFIELD AVENUE IRVINGTON NJ 07111 SUSPENSION 2/2/2008
VIGGIANO, DIANE RN 5/24/1989 188 COACHMAN DRIVE N FREEHOLD NJ 07728 DISQUALIFICATION 7/22/2017
VILLAMOR, MANUEL THERAPIS
T
11/8/1953 9030 SW 29TH TERRACE MIAMI FL 33155 SUSPENSION 3/20/2005
VILLONE, MARY 10/13/1956 DUNMORE STREET JIM THORPE PA 18512 DISQUALIFICATION 5/4/2005
VILSHTEYN, ROSTISLAV 9/7/1978 50 PAMELA LANE STATEN ISLAND NY 10304 DISQUALIFICATION 10/31/2012
VINCI, JUDITH RN 12/21/1948 202 BRUNSWICK AVENUE SPOTSWOOD NJ 08884 SUSPENSION 6/19/2003
VINING, DONNA DO 12/27/1950 33 1/2 PEMBROOKE RD. DANBURY CT 06811 DEBARMENT 7/5/2001
VIRZI, JOSEPH PO BOX 164 JAMESBURG NJ 08831 SUSPENSION 1/9/1996
VISCOMI, DOMINIC A. DDS 10/29/1941 926 DUCK POND RD. NEWTON NJ 07860 DEBARMENT 5/31/2001
VISCONTI, PAUL A. DO 8/2/1940 1538492400 120 OLD COMMACK RD. KINGS PARK NY 11754 DEBARMENT 6/27/2001 10/25/2013
VITALE, JACK RPH 9/5/1940 17 CORNELL PLACE MANALAPAN NJ 07726 SUSPENSION 6/22/1999
VITALE, JACK RPH 9/5/1940 17 CORNELL PLACE MANALAPAN NJ 07726 SUSPENSION 5/2/2000
VITALI, JOHN MD 12/5/1961 1609829985 1 SHIRA LANE MANALAPAN NJ 07726 DEBARMENT 1/22/2016
VITALI, JOHN MD 12/5/1961 1609829985 1 SHIRA LANE MANALAPAN NJ 07726 DISQUALIFICATION 6/3/2016
VOGEL III, FRANK MD 1/6/1945 271 BELMONT PLACE MAHWAH NJ 07430 DEBARMENT 8/28/2014
VOGEL, BARRY M. MD 5/26/1942 200 HIGHLAND AVENUE GLEN RIDGE NJ 07028 DEBARMENT 9/8/2000
VOROBYEV, LEONID MD 4/10/1961 1245259431 PERRY STREET MORGANVILLE NJ 07751 SUSPENSION 8/20/2008 6/17/2014
VOYTENKO, CONSTANTINE DC 10/10/1971 1174556229 2780 WEST 5TH STREET, APT.
12A
BROOKLYN NY 11224 DISQUALIFICATION 2/11/2016
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
133
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
VOZNYUK, PETRO CHHA 1/7/1954 5 PULAWSKI AVENUE SOUTH RIVER NJ 08882 DISQUALIFICATION 2/20/2017
VOZNYUK, PETRO CHHA 1/7/1954 5 PULAWSKI AVENUE SOUTH RIVER NJ 08882 DEBARMENT 4/18/2017
WACTOR, DONNA RN 6/26/1955 71 FOREST STREET MONTCLAIR NJ 07042 SUSPENSION 6/19/2003
WAGERS, DAVID OD 8/12/1970 1710928239 540 OLD FARM ROAD PALMYRA PA 17078 DISQUALIFICATION 11/20/2015
WALDRON, JOHN F. MD 6/20/1914 920 CEDARBRIDGE RD. BRICKTOWN NJ 08723 DISQUALIFICATION 6/21/1979
WALKER, ASHLEY RN/PA 5/1/1989 841 HILLTOP RD. ERIE PA 16509 DISQUALIFICATION 11/20/2015
WALKER, BARBARA D. CHHA 120 N. ORATON PARKWAY,
APT. 21
EAST ORANGE NJ 07017 DISQUALIFICATION 7/20/2002
WALKER, RUSSELL 12/20/1983 910 MORNING GLORY ROAD JACKSON NJ 08527 DISQUALIFICATION 1/10/2010
WALL PHARMACY 2510 BELMAR BOULEVARD WALL NJ 07719 SUSPENSION 2/5/2003
WALLER, ALFONSO H. MD 3/14/1931 131 37TH STREET UNION CITY NJ 07087 DISQUALIFICATION 9/14/1983
WALLIS, JODIE RN 11/17/1964 601 FAIRVIEW LANE WILLINGBORO NJ 08046 SUSPENSION 10/18/2001
WARD, KEVIN DDS 8/13/1957 1487842647 27 FIRETOWER ROAD BUDD LAKE NJ 07828 DEBARMENT 9/15/2017
WASHINGTON JR.,
ANKOMO
CHHA 7/30/1993 174 EAST 6TH STREET CLIFTON NJ 07011 DISQUALIFICATION 2/8/2017
WASHINGTON, JOHN 9/13/1951 2 TUERS PLACE MONTCLAIR NJ 07043 SUSPENSION 4/29/1997
WASHINGTON,
WAH'TAYVIA
CHHA 11/28/1991 144 BIDWELL AVENUE JERSEY CITY NJ 07305 DISQUALIFICATION 2/8/2017
WASSEF, ADEL A. MD 2/10/1932 123 SOUTH MUNN AVENUE EAST ORANGE NJ 07019 SUSPENSION 2/18/1998
WATSON, LORENZO PHARM
TECH
8/7/1984 500 ADAMS LANE NORTH BRUNSWICK NJ 08902 DISQUALIFICATION 11/21/2016
WATSON, MARC C. MD 2/29/1948 1578605929 912 POMPTON AVENUE, #9B1 CEDAR GROVE NJ 07009 SUSPENSION 4/1/2001
WATSON, TRACEY L. LPN 12/23/1970 1 GRUMMAN AVENUE, APT.
4F
NEWARK NJ 07112 DISQUALIFICATION 1/23/2006
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
134
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
WATZMAN, MARC
HOWARD
MD 7/6/1966 PO BOX 1000 LORETTO PA 15940 DEBARMENT 8/30/2007
WEAH, JEROME 2/23/1976 PO BOX 190 AVENEL NJ 07001 DISQUALIFICATION 1/14/2011
WEBB, ALNESHA CHHA 1/7/1993 328 IRVINE TURNER ROAD NEWARK NJ 07108 DISQUALIFICATION 1/29/2018
WEBB, CURTIS O. RN 12/23/1952 110 CROSSHILL DR BANGOR PA 18013 SUSPENSION 12/19/2002
WEBER, MARC DDS 6/2/1966 1609064062 326 BROAD STREET RED BANK NJ 07701 SUSPENSION 11/5/2009 9/30/2010
WEBER, MARGARET LPN 10/23/1958 2920 STATE RTE. 23 NEWFOUNDLAND NJ 07435 SUSPENSION 12/18/2003
WEIDER, ABE 3301 FOSTER AVENUE BROOKLYN NY 11203 SUSPENSION 12/21/2001
WEIGAND, DAVID RN 1/13/1969 310 VILLAGE DRIVE SOMERSET NJ 08873 SUSPENSION 3/20/2001
WEIN, FRED R. RPH 10/5/1953 111 TANGERINE DRIVE MARLBORO NJ 07746 SUSPENSION 5/19/2005
WEINSTEIN, LEONARD MD 10/15/1931 1 TRENT RD. MONROE TWP. NJ 08831 SUSPENSION 8/20/2003
WEINSTEIN, MARTIN H. DPM 12/30/1955 601 2ND AVENUE LONG BRANCH NJ 07740 DISQUALIFICATION 6/19/2008
WEINTRAUB, FREDERICK DPM 10/12/1951 1225131550 17 HARVEY LANE UPPER SADDLE
RIVER
NJ 07458 DISQUALIFICATION 2/15/2016
WEISELBERG, ALAN 12/7/1945 8900 S.W. 61ST STREET MIAMI FL 33156 DISQUALIFICATION 6/5/2000
WEISS, CHERIE PA 4/21/1976 1861435828 801 ABBEY RD. MIDDLETOWN NJ 07748 DEBARMENT 12/16/2015
WEISS, MURRAY 12/25/1925 80 SKY MEADOW WHITE PLAINS NY 10607 DISQUALIFICATION
WELCH, SHIRLEY 5/8/1947 SCENIC DRIVE FREEHOLD NJ 07728 SUSPENSION 8/20/2007
WELLES, ANTONNETTE CHHA 10/21/1994 124 S. OLDEN AVENUE TRENTON NJ 08609 DISQUALIFICATION 2/8/2017
WELLS, CHRISTOPHER W. RPH 1/19/1966 WARRENS WAY WANAQUE NJ 07645 DEBARMENT 10/1/2007
WELLS, TAMARA RN 2/9/1960 13 HENRY STREET BERGENFIELD NJ 07621 DISQUALIFICATION 6/8/2018
WELLS, WARREN CHHA 11/1/1971 202 BEAR BROOK ACRES
DRIVE
MADISON
TOWNSHIP
PA 15663 DISQUALIFICATION 11/20/2015
WERTHEIM, HOWARD RPH 8/18/1948 19 KNOB HILL RD. HACKETTSTOWN NJ 07840 SUSPENSION 12/20/2004
WERTHEIM, HOWARD RPH 8/18/1948 696A FRIAR COURT MANCHESTER NJ 08759 DISQUALIFICATION 12/12/2016
WERTHEIM, MARC DDS 10/9/1964 1306910427 24 MERCHANTS WAY COLTS NECK NJ 07722 DEBARMENT 8/25/2009
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State of New Jersey
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
135
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
WERTHEIM, MARC DDS 10/9/1964 1306910427 80 E. JOSEPH STREET MOONACHIE NJ 07074 DISQUALIFICATION 1/20/2013
WESHNAK, NADIA LPN/RN 1/23/1962 382 WOODLAKE MANOR DR. LAKEWOOD NJ 08701 SUSPENSION 10/20/2002
WESLEY, JOSEPH W. MD 10/9/1948 246 N FRANKLIN TPK RAMSEY NJ 07446 DISQUALIFICATION 6/19/2002
WESLEY, LACHAE'YA CHHA 7/9/1989 732 OCEAN AVENUE, APT. 11 LONG BRANCH NJ 07740 DISQUALIFICATION 4/18/2017
WESLEY, NUEDAH 7/27/1973 10 ROANOKE COURT WILLINGBORO NJ 08046 DEBARMENT 5/28/2013
WEST ORANGE PHARMACY 1548326812 11 DOGWOOD LANE EAST HANOVER NJ 07936 DISQUALIFICATION 3/29/2017 PERMANENT
WESTFIELD AVENUE
PHARMACY
156 COUNTRY FARM ROAD MARLTON NJ 08053 DISQUALIFICATION 9/26/2013
WESTON, MARC OD 4/18/1937 16 BARNETT RD LAWRENCEVILLE NJ 08648 DISQUALIFICATION 6/1/1993
WHETSTONE, RHONDA CHHA 8/9/1983 73 PEABODY PLACE NEWARK NJ 07104 DISQUALIFICATION 7/27/2017
WHITE, PHAEDRA J. RN 3/5/1966 1107 N SALINA ST. #2 SYRACUSE NY 132082 DEBARMENT 11/20/2008
WHITE, WAYNE RPH 4/14/1960 1366717514 11001 NORTHWEST 17TH
AVENUE
MIAMI FL 33167 DISQUALIFICATION 11/20/2015
WHITE, WENDELL CHHA 4/15/1969 106B CHAUCER RD. MOUNT LAUREL NJ 08054 DEBARMENT 10/25/2003
WHITEHEAD, TARSHEEKA CHHA 1/4/1983 1751 OLIVER STREET RAHWAY NJ 07065 DISQUALIFICATION 2/8/2017
WHITEMAN, GERALD J. DDS 2/5/1939 1821191982 RIVERGATE WAY LONG BRANCH NJ 07740 DISQUALIFICATION 1/5/2007
WHITMORE, SHARON T. 1/8/1967 51 DOVER ST., 2ND FLOOR NEWARK NJ 07106 DEBARMENT 9/19/2002
WHITMORE, SHARON T. 1/8/1967 51 DOVER STREET 2ND FLOOR NEWARK NJ 07106 DISQUALIFICATION 8/15/2005
WHITNEY, MARIS AKA
WERBIN, MARIS
RPH 8/11/1957 126 RIVER DRIVE LAKE HIAWATHA NJ 07034 SUSPENSION 8/20/2006
WHITTAKER, MICHELLE CHHA 6/4/1992 801 1/2 4TH AVENUE NEPTUNE NJ 07753 DEBARMENT 8/29/2017
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Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
136
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
WIJETILAKA, ROHAN MD 12/8/1948 1821058694 FORT DIX FCI - PO BOX 2000 FORT DIX NJ 08640 DISQUALIFICATION 5/20/2015
WIKLINSKI, STEPHEN L. DC 10/1/1964 1659454981 DEWOLF RD. OLD TAPPAN NJ 07675 SUSPENSION 10/18/2001
WILKING, JULIE RN 8/7/1979 415B WHITMAN DRIVE HADDONFIELD NJ 08033 DISQUALIFICATION 5/2/2017
WILKINSON, PHYLLIS LPN 7/5/1963 8 WINDING RIDGE COURT NEPTUNE NJ 07753 SUSPENSION 9/20/2006
WILLARD, VANCE CHHA 4/17/1956 283 FORD AVENUE WESTWOOD NJ 07675 DEBARMENT 1/25/2018
WILLER, MAURICE MD 3/19/1928 631 NYE AVENUE IRVINGTON NJ 07111 DEBARMENT 11/6/2000
WILLIAMS JR., OTIS A. MD 11/9/1962 106 W. PALISADE AVE STE201 ENGLEWOOD NJ 07631 SUSPENSION 7/27/1998
WILLIAMS JR., OTIS A. MD 11/9/1962 293 CLASSON AVE., APT. 2R BROOKLYN NY 11205 SUSPENSION 2/2/1999
WILLIAMS, AMY 5/14/1967 1126 COLLINS RD. CAMDEN NJ 08104 DEBARMENT 7/15/2004
WILLIAMS, ARNISSA 2/18/1974 256 1/2 SOUTH 19TH STREET NEWARK NJ 07103 DISQUALIFICATION 3/25/2006
WILLIAMS, BEATRICE CHHA 1/28/1947 37 VIVIAN COURT HOWELL NJ 07731 DISQUALIFICATION 4/22/2002
WILLIAMS, CONRAD D. MD 1/28/1949 1841410701 255 EASTERN PARKWAY, APT.
A16
BROOKLYN NY 11238 DISQUALIFICATION 8/20/2015
WILLIAMS, CRAIG DMD 3/30/1957 175 CROSS KEYS RD. BERLIN NJ 08009 SUSPENSION 1/18/2007
WILLIAMS, DENEESHAH CHHA 11/6/1991 133 WILLIAM STREET ROSELLE NJ 07203 DISQUALIFICATION 2/8/2017
WILLIAMS, DESHAWNA CHHA 11/26/1989 112 CORAL STREET PATERSON NJ 07522 DISQUALIFICATION 9/26/2017
WILLIAMS, DIONE MD 12/15/1958 1356437693 1787 SPRINGFIELD AVENUE MAPLEWOOD NJ 07040 DEBARMENT 12/16/2015
WILLIAMS, HELIEN 1/25/1986 29 STRATFORD PLACE, APT. 2F NEWARK NJ 07104 DISQUALIFICATION 8/26/2013
WILLIAMS, JAMES LLOYD THERAPIS
T
5/26/1966 208 NORTH CHESTNUT
STREET
SCOTTDALE PA 15683 DISQUALIFICATION 11/20/2015
WILLIAMS, JEWEL CHHA 6/3/1990 944 MORTON STREET CAMDEN NJ 08105 DEBARMENT 9/23/2014
WILLIAMS, JOHKEMIA CHHA 11/26/1981 7 MELLON STREET TRENTON NJ 08618 DISQUALIFICATION 2/8/2017
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State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
137
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
WILLIAMS, MARCUS MD 6/19/1958 1619057734 1500 LOCUST STREET, APT.
3912
PHILADELPHIA PA 19102 DISQUALIFICATION 11/20/2015
WILLIAMS, MECCA CHHA 12/7/1992 126 PARKER STREET NEWARK NJ 07104 DISQUALIFICATION 2/8/2017
WILLIAMS, VINETTIA 3/6/1966 418 SASSAFRAS STREET MILLVILLE NJ 08360 SUSPENSION 8/20/2006
WILLIAMS-KLENA, JOAN 7/7/1933 103 KOMORN STREET NEWARK NJ 07105 DISQUALIFICATION 6/17/1987
WILLIAMSON, HELEN 11/4/1981 41 ATLANTIC AVENUE MANAHAWKIN NJ 08050 SUSPENSION 2/20/2008
WILLS, LAURA LPN 5/12/1989 14 E. WIND TRAIL, #22 FAIRFIELD PA 17320 DISQUALIFICATION 11/20/2015
WILSHIRE, GILBERT MD 5/11/1961 1386679298 1120 ROUTE 22 E BRIDGEWATER NJ 08807 DEBARMENT 12/3/1999
WILSON III, FRANKIE M. 3/10/1941 395 NORTH GROVE STREET EAST ORANGE NJ 07017 DEBARMENT 11/24/2007
WILSON, ELLEN RN/APN 2/3/1975 1144406620 42 THEO COURT BURLINGTON NJ 08016 DISQUALIFICATION 11/20/2015 10/27/2017
WILSON, EVELYN LCSW 4/30/1941 209 W. HUDSON AVENUE ENGLEWOOD NJ 07631 DISQUALIFICATION 8/15/2007
WILSON, IAN 6/6/1955 724 GROVE ST IRVINGTON NJ 07111 DISQUALIFICATION 12/24/1985
WILSON, TAKEELA CHHA 8/31/1979 135 BERGEN AVENUEM APT. 2-
E
JERSEY CITY NJ 07305 DISQUALIFICATION 4/7/2017
WILSON, TASHA M. CHHA 8/25/1971 124 YORK ST., APT.64 SALEM NJ 08079 DISQUALIFICATION 1/6/2006
WINDMILLER, EDWARD DDS 5/30/1961 1871914036 3731 WALNUT STREET, APT. A HARRISBURG PA 17109 DISQUALIFICATION 12/29/2015
WINEGARDEN, ROBERT F. DMD 1/21/1949 1306056981 1 ROUTE 27, PARSONAGE RD EDISON NJ 08820 SUSPENSION 9/20/1999
WINEGRAD, ALBERT MD 9/26/1926 1972752855 3220 LENAPE DRIVE DRESHER PA 19025 DISQUALIFICATION 11/20/2015
WINGROVE DRUGS, INC. 634 DR. MARTIN L. KING
BOULEVARD
NEWARK NJ 07102 SUSPENSION 6/5/1997
WINKY, INC. 2510 BELMAR BOULEVARD WALL NJ 07719 DISQUALIFICATION 1/11/2005
WINTER, JESSICA CHHA 7/9/1986 426 CATHERINE STREET BERGENFIELD NJ 07621 DISQUALIFICATION 2/20/2017
WINTHER-GALIMORE,
BETHANY
DC 2/1/1975 1134140601 1152 W. US HIGHWAY 54 CAMDENTON MO 65020 DISQUALIFICATION 9/20/2011
WISCH, GLENN R. DMD 12/1/1955 6-05 SADDLE RIVER RD. FAIRLAWN NJ 07410 DISQUALIFICATION 4/29/1996
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
138
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
WITEK JR., JOSEPH T. MD 4/28/1969 1063606838 3625 AVENIDA MADEIRA BRADENTON FL 34210 DEBARMENT 10/17/2000
WITHINGTON, PAMELA RN 9/9/1960 5 CHERRYVILLE RD. FLEMINGTON NJ 08822 SUSPENSION 6/20/2005
WITMAN, LEEANN 12/30/1964 SCI CAMBRIDGE SPRINGS, 451
FULLERTON AVENUE
CAMBRIDGE
SPRINGS
PA 16403 DISQUALIFICATION 11/20/2015
WOLF, JEFFREY A. DPM 9/14/1948 1100 CLIFTON AVENUE CLIFTON NJ 07103 DISQUALIFICATION 10/14/1997
WOLFE, JOSEPH ROUTE 24 MENDHAM NJ 07945 DISQUALIFICATION 6/1/1993
WOLFE, MARY LPN 10/5/1953 2760 PINE GROVE RD. YORK PA 17403 DISQUALIFICATION 11/20/2015
WOLFE, WILLIAM MD 10/5/1963 1003872912 27 ROCKINGHAM DRIVE MARLTON NJ 08053 DISQUALIFICATION 9/12/2016
WOLFF, MICHAEL W. LPN 4/15/1986 178 WHITES HILL ROAD ROCHESTER PA 15074 DISQUALIFICATION 12/29/2015
WOLFSON, STANLEY MD 11/3/1929 5 CLUBWAY LANE HARTSDALE NY 10530 SUSPENSION 4/19/2001
WOLLMAN, ROBERT DDS 5/11/1951 1659429421 461 CENTRAL AVENUE JERSEY CITY NJ 07307 DISQUALIFICATION 11/6/1987
WOOD, FAYE W. CHHA 6/30/1958 33 WHITE OAK DRIVE PRINCETON NJ 08540 DISQUALIFICATION 9/25/2002
WOODS, CALEDA CHHA 7/25/1977 158 GIRARD AVENUE TRENTON NJ 08638 DISQUALIFICATION 2/8/2017
WOODSON, BASSEY
JUSTICE
10/4/1962 32 DAYTON STREET, APT. B1 NEWARK NJ 07114 DISQUALIFICATION 9/13/2013
WOROSILO, SHARON MD 12/18/1960 1000 AVENUE AT PORT
IMPERIAL
WEEHAWKIN NJ 07086 DISQUALIFICATION 11/8/2017
WOUND HEALING
ASSOCIATES
3111 ROUTE 38 MOUNT LAUREL NJ 08054 SUSPENSION 11/19/2005
WOZUNK, GEORGE 9/23/1963 1029 E. PARK AVENUE VINELAND NJ 08360 SUSPENSION 3/10/2000
WREH-TOE, PALLEH 9/1/1964 3401 MERLOT COURT YORK PA 17404 DISQUALIFICATION 12/29/2015
WREIOLE, AUGUST DO 8/21/1949 1942247333 422 MORRIS AVENUE LONG BRANCH NJ 07740 DEBARMENT 7/8/2017
WRIGHT, KIMBERLY A. RN 8/15/1965 27 GLENSIDE AVENUE SUMMIT NJ 07901 SUSPENSION 10/20/2002
WRIGHT, LYNN I. 2/23/1970 84 PENN STREET BRIDGETON NJ 08090 SUSPENSION 8/17/2008
WRIGHT, SALLY A. PSYCH 10/27/1953 1497769160 GLEN RAY RD. BOX A ALDERSON WV 24910 DEBARMENT 9/19/2011
WRIGHT, SANDRA CHHA 6/22/1957 4938 NORTH 8TH STREET PHILADELPHIA PA 19120 DISQUALIFICATION 11/20/2015
WRIGHT, SHELLY L. RN 9/10/1959 MURTLAND STREET SPRINGDALE PA 15144 DISQUALIFICATION 9/23/2007
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
139
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
WRIGHT, SHONEYEH 9/22/1982 CLINTON AVENUE IRVINGTON NJ 07111 DEBARMENT 10/5/2007
WRIGHT, SYDNEY CHHA 8/22/1991 111 SHERWOOD AVENUE MAHWAH NJ 07430 DISQUALIFICATION 4/18/2017
WUJACK, ALLISON LPN 10/25/1983 308A SUNRISE BOULEVARD FORKED RIVER NJ 08731 DISQUALIFICATION 5/2/2017
WYLES, KIMBERLY CHHA 12/31/1989 116 BLACKWOOD-
CLEMONTON ROAD
CLEMONTON NJ 08021 DEBARMENT 3/5/2018
WYLIE, JOHN D. RPH 11/28/1950 7306 WOODVIEW WAY MALVERN PA 19355 SUSPENSION 7/20/2004
YAEGER, CHARLES 8/30/1978 21 BARKALOW AVENUE FREEHOLD NJ 07728 DISQUALIFICATION 6/5/2008
YAEGER, HOPE W. RN 9/30/1969 1316 S. 10TH ST, APT. 2 ALLENTOWN PA 18103 SUSPENSION 8/20/2001 1/5/2018
YAKHNIS, ANNA RN 8/31/1975 28 SAINT MICHAELS COURT CHURCHVILLE PA 18966 DISQUALIFICATION 11/20/2015
YALE, DONNA APPEL LPN 5/2/1954 49 ANGLE INN TRAILER CRT FARMINGDALE NJ 07727 SUSPENSION 9/20/2000
YANGBE, PATIENCE CHHA 2/19/1990 730 FRANKLIN STREET TRENTON NJ 08610 DISQUALIFICATION 2/8/2017
YATES, QIANNA CHHA 5/5/1979 209 EUTAW STREET CAMDEN NJ 08105 DISQUALIFICATION 4/19/2018
YAW, GAYFORD A. PHARM
TECH
5/11/1963 504 STEVENS RD. LANDING NJ 07050 SUSPENSION 5/20/2008
YAW, GAYFORD A. PHARM
TECH
5/11/1963 504 STEVENS RD. LANDING NJ 07850 DISQUALIFICATION 9/24/2008
YELCICK, JOHN MD 5/15/1965 635 WILLOW GREEN LITITZ PA 17543 DEBARMENT 7/28/2014
YEPES, LINA CHHA 1/19/1980 2105 NEW YORK AVENUE,
BSMT 3
UNION CITY NJ 07087 DISQUALIFICATION 2/20/2017
YEPES-SANCHEZ, ONAIDA CHHA 10/9/1961 1815 PALLISADE AVENUE UNION CITY NJ 07086 DISQUALIFICATION 2/8/2017
YOON, TOL UNG MD 2/15/1941 9 MALAGA DRIVE BRIDGETON NJ 08302 DISQUALIFICATION 12/1/1998
YOUNG, JULIA CHHA 9/9/1975 2019 SOUTH 9TH STREET CAMDEN NJ 08104 DISQUALIFICATION 2/20/2017
YOUNGER, ANTHONY 11/24/1969 65 MAIDEN LANE LITTLE FERRY NJ 07643 DEBARMENT 10/15/2008
YULE, ROBERT C. RN 6/23/1948 323 FLORENCE RD. MIDDLETOWN NJ 07748 SUSPENSION 9/19/2003
YUNATANOV, STEVE DDS 4/7/1965 1366749962 83-83 118 TH STREET KEW GARDENS NY 11415 SUSPENSION 7/20/2004
ZAINELABDIN, AMID 12/12/1950 126 CORBIN AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 5/21/2002
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format
State of New Jersey
Medicaid Fraud Division
Provider Exclusion Report**ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES**
140
Updated on: 8/24/2018
PROVIDER NAME TITLE DATE OF
BIRTH
NPI NUMBER STREET CITY STATE ZIP ACTION EFFECTIVE
DATE
EXPIRATION
DATE
ZAK, FELIX 4/13/1952 825 E. 9TH STREET BROOKLYN NY 11230 DISQUALIFICATION 1/9/2001
ZAMAN, TANVIR PHARM
TECH
9/25/1980 205 DAVIS AVENUE ABSECON NJ 08201 DISQUALIFICATION 7/18/2018
ZAMLOOT, PHILIP 10/28/1969 150 PARK ROW NEW YORK NY 10007 SUSPENSION 7/20/2005
ZARRELLI, MICHAEL
#67206-050
12/13/1966 FCI FORT DIX - PO BOX 2000 JOINT BASE MDL. NJ 08640 DISQUALIFICATION 9/29/2017
ZASLOW, LAWRENCE RPH 12/7/1953 323 SOCIETY HILL BLVD., APT
1
CHERRY HILL NJ 08003 DISQUALIFICATION 10/25/2016
ZAWAHIR, MEEYAPILLAI 2/22/1939 91 KNICKERBOCKER RD. TENAFLY NJ 07670 SUSPENSION 9/20/2006
ZELTSER, LAZAR 4/11/1973 2333 MORRIS AVENUE, UNIT
D3
UNION NJ 07083 SUSPENSION 6/22/1998
ZELTSER, RAISA 9/11/1970 6 PLEASANT VALLEY WAY WEST ORANGE NJ 07079 SUSPENSION 9/14/2000
ZERKTI, HOUDA CHHA 7/26/1982 72 KENNEDY BOULEVARD BAYONNE NJ 07002 DISQUALIFICATION 2/8/2017
ZIBDIE, YOUSEF MD 5/5/1964 1598714784 163 WEBSTER DRIVE WAYNE NJ 07470 DEBARMENT 12/11/2017
ZIHALA, TERESA RN 7/25/1961 148 MAIN STREET SPOTSWOOD NJ 08884 SUSPENSION 9/19/2003
ZIMMERMAN, DANIEL MD 10/13/1947 1801919741 51 ROCKLEDGE ROAD HAWTHORNE NJ 07506 DEBARMENT 12/7/1999 9/5/2012
ZIMMERMAN, DANIEL MD 10/13/1947 1801919741 501 BARCLAY WALK CHERRY HILL NJ 08034 DISQUALIFICATION 11/23/2016
ZIMNA, GRAZYNA CHHA 3/14/1963 19 NEW JERSEY AVENUE CARTERET NJ 07008 DISQUALIFICATION 2/20/2017
ZUBAIR, SAIRA 3/1/1971 18 RAVENSWOOD LANE SCOTCH PLAINS NJ 07076 DEBARMENT 8/1/2017
ZUBERI, REHAN 1/4/1969 FLUSHING NY 11355 DEBARMENT 2/18/1999 11/17/2011
ZUBERI, REHAN 1/4/1969 MID-STATE CORRECTIONAL
FACILITY, PO BOX 866
WRIGHTSTOWN NJ 08562 DISQUALIFICATION 2/28/2018 PERMANENT
ZUCKERMAN, DAVID H. DPM 4/11/1954 1124024435 341 S. EVERGREEN AVENUE WOODBURY NJ 08096 DEBARMENT 1/15/2012
ZUCKERMAN, DAVID H. DPM 4/11/1954 1124024435 1803 COUNTRY CLUB DRIVE CHERRY HILL NJ 08003 DISQUALIFICATION 9/20/2012
ZUNIGA, GUISELLA CHHA 1/12/1980 74B WEST SECOND STREET BOUND BROOK NJ 08805 DISQUALIFICATION 5/8/2018 PERMANENT
ZWIERCAN, ANDREW RPH 6/19/1957 601 BERGEN STREET SOUTH PLAINFIELD NJ 07080 DEBARMENT 6/20/2016
For verifications
please contact: [email protected] Send an email to [email protected] to receive this report in .xls format