Provider Demographics
NPI:1194385682
Name:AGUILLON, DIEGO ERNESTO (PTA)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:ERNESTO
Last Name:AGUILLON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-1049
Mailing Address - Country:US
Mailing Address - Phone:203-365-6443
Mailing Address - Fax:
Practice Address - Street 1:4200 PARK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-1049
Practice Address - Country:US
Practice Address - Phone:203-365-6443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1408225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant