Healthcare Provider Details

I. General information

NPI: 1164497624
Provider Name (Legal Business Name): JOSE R FRAGOSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOSE R FRAGOSO MD

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4808 BERGENLINE AVE 5TH FLOOR
UNION CITY NJ
07087-5172
US

IV. Provider business mailing address

4808 BERGENLINE AVE 5TH FLOOR
UNION CITY NJ
07087-5172
US

V. Phone/Fax

Practice location:
  • Phone: 201-865-3444
  • Fax: 201-865-0038
Mailing address:
  • Phone: 201-865-3444
  • Fax: 201-865-0038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA04358900
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier81801
Identifier TypeOTHER
Identifier StateNH
Identifier IssuerAMERIGROUP
# 2
IdentifierHP080
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerOXFORD
# 3
Identifier1140004
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerHORIZON NJ HEALTH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: