Individual
DR. JACK FACCIOLO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
1 SECLUDED LN, RIO GRANDE, NJ 08242-1546
(609) 368-1952
Mailing address
1 SECLUDED LN, RIO GRANDE, NJ 08242-1546
(609) 368-1952
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MB039210
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0090462000
INDP BCBS PROVIDER NUMBER
NJ
01
—
1074056
HORIZON NJ HEALTH NUMBER
NJ
01
—
1213261003
CIGNA PPO NUMBER
NJ
05
—
2345005
—
NJ
01
—
825040
CIGNA HMO NUMBER
NJ
01
—
CMS005
OXFORD PROVIDER NUMBER
NJ
Enumeration date
03/16/2006
Last updated
12/01/2009
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