Provider Demographics
NPI:1972236131
Name:JACK BASIL DANGELO JR
Entity Type:Organization
Organization Name:JACK BASIL DANGELO JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-748-8341
Mailing Address - Street 1:3 CARPENDER RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1501
Mailing Address - Country:US
Mailing Address - Phone:917-748-8341
Mailing Address - Fax:
Practice Address - Street 1:191 BRADLEY AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-5166
Practice Address - Country:US
Practice Address - Phone:917-748-8341
Practice Address - Fax:917-970-9703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01484220Medicaid