Provider Demographics
NPI:1073120739
Name:BARACALDO, BRYAN (DPT)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BARACALDO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E GATE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2105
Mailing Address - Country:US
Mailing Address - Phone:516-745-8070
Mailing Address - Fax:
Practice Address - Street 1:1000 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5338
Practice Address - Country:US
Practice Address - Phone:516-466-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist