Provider Demographics
NPI:1104365592
Name:KING, SEAN GERARD (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:GERARD
Last Name:KING
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 1:175 ROUTE 70 W
Mailing Address - Street 2:#19
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2300
Mailing Address - Country:US
Mailing Address - Phone:609-714-3378
Mailing Address - Fax:
Practice Address - Street 1:115 ROUTE 73 N
Practice Address - Street 2:#80
Practice Address - City:BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08009
Practice Address - Country:US
Practice Address - Phone:856-335-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist