Provider Demographics
NPI:1821478744
Name:ANNUNZIATO, JACK (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:ANNUNZIATO
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 1:1200 E RIDGEWOOD AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3937
Mailing Address - Country:US
Mailing Address - Phone:201-612-4857
Mailing Address - Fax:
Practice Address - Street 1:1200 E RIDGEWOOD AVE STE 306
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3937
Practice Address - Country:US
Practice Address - Phone:201-612-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10536200204D00000X, 208100000X
PAOT016359390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program