# JACK BASIL DANGELO JR

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1972236131
- **Authorized official:** JACK D'ANGELO MD (PRESIDENT)
- **Authorized official phone:** (917) 748-8341

## Contact information

- **Practice address:** 191 BRADLEY AVE, STATEN ISLAND, NY 10314-5166
- **Practice address phone:** (917) 748-8341
- **Practice address fax:** (917) 970-9703
- **Mailing address:** 3 CARPENDER RD, NEW BRUNSWICK, NJ 08901-1501
- **Mailing address phone:** (917) 748-8341

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | NULL | Yes |
| 208100000X | Physical Medicine & Rehabilitation Physician | — | — | Yes |

## Other

- **Enumeration date:** 07/06/2022
- **Last updated:** 07/06/2022