Provider Demographics
NPI:1245204650
Name:DANGELO, JACK BASIL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BASIL
Last Name:DANGELO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:BASIL
Other - Last Name:D'ANGELO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3 CARPENDER RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1501
Mailing Address - Country:US
Mailing Address - Phone:732-545-5771
Mailing Address - Fax:
Practice Address - Street 1:191 BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5166
Practice Address - Country:US
Practice Address - Phone:917-748-8341
Practice Address - Fax:917-970-9703
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195391208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01484220Medicaid