Provider Demographics
NPI:1366444879
Name:DIPPOLITO, JACK A (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:A
Last Name:DIPPOLITO
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 1:71 VALENTINE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542
Mailing Address - Country:US
Mailing Address - Phone:845-624-3909
Mailing Address - Fax:845-624-3909
Practice Address - Street 1:71 VALENTINE AVE
Practice Address - Street 2:
Practice Address - City:GLENCOVE
Practice Address - State:NY
Practice Address - Zip Code:11542
Practice Address - Country:US
Practice Address - Phone:845-624-3909
Practice Address - Fax:845-624-3909
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NYX1732111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXO7111Medicare UPIN