Provider Demographics
NPI:1164497624
Name:FRAGOSO, JOSE R (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:R
Last Name:FRAGOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOSE
Other - Middle Name:R
Other - Last Name:FRAGOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4808 BERGENLINE AVE
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-5172
Mailing Address - Country:US
Mailing Address - Phone:201-865-3444
Mailing Address - Fax:201-865-0038
Practice Address - Street 1:4808 BERGENLINE AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5172
Practice Address - Country:US
Practice Address - Phone:201-865-3444
Practice Address - Fax:201-865-0038
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA043589002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH81801OtherAMERIGROUP
NJHP080OtherOXFORD
NJ1140004OtherHORIZON NJ HEALTH