Provider Demographics
NPI:1033803598
Name:FUCIK, DALTON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:FUCIK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 MILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14170-9752
Mailing Address - Country:US
Mailing Address - Phone:210-667-6420
Mailing Address - Fax:
Practice Address - Street 1:4650 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-1939
Practice Address - Country:US
Practice Address - Phone:716-648-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-07
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist