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General NPI Number Information
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NPI Number | 1972236131
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Entity Type | Organization
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Legal Business Name | JACK BASIL DANGELO JR
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Dates
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Enumeration Date | 07/06/2022
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Last Update Date | 07/06/2022
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Provider Practice Location Address
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Address Line | 191 BRADLEY AVE
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City | STATEN ISLAND
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State | NY
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Zip | 10314-5166
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Country | US
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Telephone | 917-748-8341
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Fax | 917-970-9703
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Provider Business Mailing Address
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Address Line | 3 CARPENDER RD
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City | NEW BRUNSWICK
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State | NJ
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Zip | 08901-1501
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Country | US
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Telephone | 917-748-8341
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JACK D'ANGELO
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Credential | MD
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Telephone | 917-748-8341
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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