Provider Demographics
NPI:1063503555
Name:BANIGO, SAMUEL A (MD,)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
Last Name:BANIGO
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OFFICE MANAGER
Mailing Address - Street 1:105 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-2410
Mailing Address - Country:US
Mailing Address - Phone:908-245-3637
Mailing Address - Fax:973-375-5766
Practice Address - Street 1:40 UNION AVE
Practice Address - Street 2:STE.204
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3277
Practice Address - Country:US
Practice Address - Phone:973-416-6981
Practice Address - Fax:973-375-5766
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07986300207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0098256Medicaid
NJI51271Medicare UPIN
NJ100041Medicare ID - Type Unspecified