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General NPI Number Information
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NPI Number | 1598777112
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Entity Type | Individual
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Provider Name | JESSE MANGONE
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Gender | Male
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 11/21/2007
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Provider Practice Location Address
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Address Line | 1117 US HIGHWAY 46 SUITE 202
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City | CLIFTON
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State | NJ
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Zip | 07013-2449
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Country | US
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Telephone | 973-614-8484
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7306
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City | EAST RUTHERFORD
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State | NJ
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Zip | 07073-7306
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Country | US
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Telephone | 973-614-8484
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 25MB03219800
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License Number State | NJ
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