Provider Demographics
NPI:1851448492
Name:CAPPITELLI, JACK V (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:V
Last Name:CAPPITELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31-00 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3963
Mailing Address - Country:US
Mailing Address - Phone:201-796-2255
Mailing Address - Fax:201-796-3711
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-796-2255
Practice Address - Fax:201-796-7020
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06342700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7482604Medicaid
NJP839684OtherOXFORD PROVIDER ID
NJOK8459OtherHEALTHNET PROVIDER ID
NJG63703Medicare UPIN
NJ7482604Medicaid