Provider Demographics
NPI:1588624340
Name:DEVITA, JACK J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:J
Last Name:DEVITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 LIPPINCOTT DR STE E
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 LIPPINCOTT DR.
Practice Address - Street 2:SUITE E
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-983-1900
Practice Address - Fax:856-983-5110
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07219400207RG0100X
NJMA07219400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2371600Medicaid
NJ8523100Medicaid
NJ046886A7RMedicare ID - Type Unspecified
046886BL3Medicare PIN
NJ2371600Medicaid
NJ8523100Medicaid