Provider Demographics
NPI:1336290980
Name:DUGO, JACK ROBERT (DC)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ROBERT
Last Name:DUGO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 HYLAN BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6501
Mailing Address - Country:US
Mailing Address - Phone:718-984-0024
Mailing Address - Fax:718-984-4036
Practice Address - Street 1:4300 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6507
Practice Address - Country:US
Practice Address - Phone:171-898-4002
Practice Address - Fax:133-629-0980
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002946-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT522671Medicare UPIN
NYX16762Medicare ID - Type Unspecified