Healthcare Provider Details

I. General information

NPI: 1346452166
Provider Name (Legal Business Name): JOSE FRAGOSO MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4808 BERGENLINE AVE
UNION CITY NJ
07087-5172
US

IV. Provider business mailing address

4808 BERGENLINE AVE
UNION CITY NJ
07087-5172
US

V. Phone/Fax

Practice location:
  • Phone: 732-281-3590
  • Fax: 732-281-0054
Mailing address:
  • Phone: 732-281-3590
  • Fax: 732-281-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMAO43589
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2062208
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. JOSE FRAGOSO
Title or Position: DOCTOR
Credential: MD
Phone: 732-281-3590