1861772063 NPI number — DR. JOSEPH ANTHONY BANDA PT, DPT, CSCS

Table of content: DR. JOSEPH ANTHONY BANDA PT, DPT, CSCS (NPI 1861772063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861772063 NPI number — DR. JOSEPH ANTHONY BANDA PT, DPT, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANDA
Provider First Name:
JOSEPH
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861772063
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 BRIGHTON RD
Provider Second Line Business Mailing Address:
SUITE 406
Provider Business Mailing Address City Name:
CLIFTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07012-1663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-928-6969
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
SUITE G3
Provider Business Practice Location Address City Name:
GLEN RIDGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07028-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-893-5082
Provider Business Practice Location Address Fax Number:
973-893-5141
Provider Enumeration Date:
08/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  40QA01404800 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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