Provider Demographics
NPI:1083687453
Name:DEJOHN, ROBERT RICHARD JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RICHARD
Last Name:DEJOHN
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 HARRIET ST
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-2309
Mailing Address - Country:US
Mailing Address - Phone:716-867-0168
Mailing Address - Fax:
Practice Address - Street 1:2540 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-9410
Practice Address - Country:US
Practice Address - Phone:716-862-0567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0001622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer