Provider Demographics
NPI:1083732796
Name:FAUSTINO, PERIPHON D (PT)
Entity Type:Individual
Prefix:
First Name:PERIPHON
Middle Name:D
Last Name:FAUSTINO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 MCCARTER HWY
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07114-2562
Mailing Address - Country:US
Mailing Address - Phone:973-643-8601
Mailing Address - Fax:973-643-8609
Practice Address - Street 1:375 MCCARTER HWY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114
Practice Address - Country:US
Practice Address - Phone:973-643-8601
Practice Address - Fax:973-643-8609
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6503225100000X
NJ40QA00810200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist