Provider Demographics
NPI:1073525614
Name:WHITNEY MEDICAL, ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:WHITNEY MEDICAL, ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGONE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-614-8484
Mailing Address - Street 1:PO BOX 7306
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-7306
Mailing Address - Country:US
Mailing Address - Phone:973-614-8484
Mailing Address - Fax:
Practice Address - Street 1:1117 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2449
Practice Address - Country:US
Practice Address - Phone:973-614-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03219800208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID NUMBER