Healthcare Provider Details

I. General information

NPI: 1083148167
Provider Name (Legal Business Name): DANIEL DIGIACOMO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 DAVIS AVE
NEPTUNE NJ
07753-4488
US

IV. Provider business mailing address

19 DAVIS AVE
NEPTUNE NJ
07753-4488
US

V. Phone/Fax

Practice location:
  • Phone: 732-776-4259
  • Fax: 732-776-2344
Mailing address:
  • Phone: 732-776-4259
  • Fax: 732-776-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number283077
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number283077
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number25MA11792000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: