Healthcare Provider Details

I. General information

NPI: 1821478744
Provider Name (Legal Business Name): JACK ANNUNZIATO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E RIDGEWOOD AVE STE 306
RIDGEWOOD NJ
07450-3937
US

IV. Provider business mailing address

1200 E RIDGEWOOD AVE STE 306
RIDGEWOOD NJ
07450-3937
US

V. Phone/Fax

Practice location:
  • Phone: 201-612-4857
  • Fax:
Mailing address:
  • Phone: 201-612-4857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number25MB10536200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT016359
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB10536200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: