Provider Demographics
NPI:1629606124
Name:ITALIANO, JACK III (DO)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:ITALIANO
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1999 MARCUS AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1021
Mailing Address - Country:US
Mailing Address - Phone:516-467-8600
Mailing Address - Fax:646-754-9820
Practice Address - Street 1:1999 MARCUS AVE STE 202
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1021
Practice Address - Country:US
Practice Address - Phone:516-467-8600
Practice Address - Fax:646-754-9820
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327932207X00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery