Provider Demographics
NPI:1063460939
Name:DACONTI, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DACONTI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 SOMME ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3612
Mailing Address - Country:US
Mailing Address - Phone:973-522-0006
Mailing Address - Fax:973-522-0666
Practice Address - Street 1:77 NEWARK AVE
Practice Address - Street 2:SUITE 3 & 4
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-4143
Practice Address - Country:US
Practice Address - Phone:973-528-2160
Practice Address - Fax:973-528-2165
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03091800207R00000X
NJXD3165075207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1287001Medicaid
NJC60796Medicare UPIN
NJ564518Medicare ID - Type Unspecified