Provider Demographics
NPI:1174620983
Name:JACKALONE, JOHN ANTHONY (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:JACKALONE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 118
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-0118
Mailing Address - Country:US
Mailing Address - Phone:516-579-3500
Mailing Address - Fax:516-579-3802
Practice Address - Street 1:4295 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5713
Practice Address - Country:US
Practice Address - Phone:516-579-3500
Practice Address - Fax:516-579-3802
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005711213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1497805931Medicare PIN
U83792Medicare UPIN
NYPG3612Medicare ID - Type Unspecified