Provider Demographics
NPI:1518967249
Name:MANICONE, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MANICONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MILLBURN AVE
Mailing Address - Street 2:SUITE 104B
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1737
Mailing Address - Country:US
Mailing Address - Phone:973-379-5888
Mailing Address - Fax:973-912-9757
Practice Address - Street 1:225 MILLBURN AVE
Practice Address - Street 2:SUITE 104B
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1737
Practice Address - Country:US
Practice Address - Phone:973-379-5888
Practice Address - Fax:973-912-9757
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05569400174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5710066OtherGHI PPO #
NJ84168OtherAMERIGROUP #
NJ0526328000OtherAMERIHEALTH #
NJ0K3218OtherHEALTHNET #
NJ5093166OtherAETNA PPO #
NJ1059497OtherHORIZON NJ HEALTH #
NJ575898OtherAETNA HMO #
NJ6893201Medicaid
NJ770001140OtherRAILROAD MDCR #
NJ5710066OtherGHI PPO #