Provider Demographics
NPI:1346452166
Name:JOSE FRAGOSO MD
Entity Type:Organization
Organization Name:JOSE FRAGOSO MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-281-3590
Mailing Address - Street 1:4808 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5172
Mailing Address - Country:US
Mailing Address - Phone:732-281-3590
Mailing Address - Fax:732-281-0054
Practice Address - Street 1:4808 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5172
Practice Address - Country:US
Practice Address - Phone:732-281-3590
Practice Address - Fax:732-281-0054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMAO43589208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2062208Medicaid