Provider Demographics
NPI:1962563932
Name:EBANI, JACK E (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:E
Last Name:EBANI
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 1:1820 CORLIES AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753
Mailing Address - Country:US
Mailing Address - Phone:732-774-4551
Mailing Address - Fax:732-774-8933
Practice Address - Street 1:1820 CORLIES AVENUE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753
Practice Address - Country:US
Practice Address - Phone:732-774-4551
Practice Address - Fax:732-774-8933
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04538800208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5043603Medicaid
B82608Medicare UPIN
NJ5043603Medicaid