Provider Demographics
NPI:1164569513
Name:MODICA, THOMAS J (PT,OTR)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:MODICA
Suffix:
Gender:M
Credentials:PT,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 FRANKLIN AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3823
Mailing Address - Country:US
Mailing Address - Phone:973-235-9585
Mailing Address - Fax:973-235-9740
Practice Address - Street 1:189 FRANKLIN AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3823
Practice Address - Country:US
Practice Address - Phone:973-235-9585
Practice Address - Fax:973-235-9740
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA003981002251X0800X
NJ46TR00191000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJMO192390Medicare ID - Type Unspecified