Provider Demographics
NPI:1558330076
Name:FACCIOLO, JACK (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:FACCIOLO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SECLUDED LN
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08242-1546
Mailing Address - Country:US
Mailing Address - Phone:609-368-1952
Mailing Address - Fax:
Practice Address - Street 1:1 SECLUDED LN
Practice Address - Street 2:
Practice Address - City:RIO GRANDE
Practice Address - State:NJ
Practice Address - Zip Code:08242-1546
Practice Address - Country:US
Practice Address - Phone:609-368-1952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB039210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1213261003OtherCIGNA PPO NUMBER
NJ2345005Medicaid
NJCMS005OtherOXFORD PROVIDER NUMBER
NJ1074056OtherHORIZON NJ HEALTH NUMBER
NJ825040OtherCIGNA HMO NUMBER
NJ0090462000OtherINDP BCBS PROVIDER NUMBER
NJ0090462000OtherINDP BCBS PROVIDER NUMBER
NJCMS005OtherOXFORD PROVIDER NUMBER