Provider Demographics
NPI:1841234341
Name:DIMARCO, JACK P (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:P
Last Name:DIMARCO
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:PO BOX 8505
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-0505
Mailing Address - Country:US
Mailing Address - Phone:856-755-1616
Mailing Address - Fax:856-755-0098
Practice Address - Street 1:1600 HADDON AVE
Practice Address - Street 2:ROOM 122
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3879
Practice Address - Fax:856-757-3760
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04166400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
484625OtherINDEPENDENCE BCBS
JS280OtherOXFORD
0108561000OtherAMERIHEALTH / KEYSTONE
853002OtherCCN
19071OtherMHCS
4197831OtherAETNA
F01770E4OtherHEALTHNET
0301021001OtherCIGNA
NJ1092688OtherHORIZON NJ HEALTH
NJ0348309Medicaid
19071OtherMHCS