Provider Demographics
NPI:1982673489
Name:VITENSON, JACK H (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:H
Last Name:VITENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:277 FOREST AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-5410
Mailing Address - Country:US
Mailing Address - Phone:201-489-8900
Mailing Address - Fax:201-489-0877
Practice Address - Street 1:277 FOREST AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-5410
Practice Address - Country:US
Practice Address - Phone:201-489-8900
Practice Address - Fax:201-489-0877
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02553900208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC57391Medicare UPIN
NJ542118CB1Medicare ID - Type Unspecified