Provider Demographics
NPI:1114974599
Name:SWIDERSKI, JOHN ROGER (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROGER
Last Name:SWIDERSKI
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 1:31 OLD ROUTE 7
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:20 GERMANTOWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5023
Practice Address - Country:US
Practice Address - Phone:203-778-4773
Practice Address - Fax:203-778-4774
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650001185Medicare ID - Type Unspecified