Provider Demographics
NPI:1215401666
Name:CHRISTODOULOU, MARIOS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARIOS
Middle Name:
Last Name:CHRISTODOULOU
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 1:770 JACKSON ST APT 839
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6973
Mailing Address - Country:US
Mailing Address - Phone:201-565-6342
Mailing Address - Fax:
Practice Address - Street 1:32 WASHINGTON ST STE 2A
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-3220
Practice Address - Country:US
Practice Address - Phone:201-565-6342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01698400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty