Provider Demographics
NPI:1164457818
Name:VICARETTI, SAMUEL JOSEPH JR (PT)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:VICARETTI
Suffix:JR
Gender:M
Credentials:PT
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Other - First Name:
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Mailing Address - Street 1:3495 BAILEY AVE
Mailing Address - Street 2:ROOM 314D
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1129
Mailing Address - Country:US
Mailing Address - Phone:716-862-6840
Mailing Address - Fax:716-862-8664
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:ROOM 314D
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-862-6840
Practice Address - Fax:716-862-8664
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY012795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist