Provider Demographics
NPI:1265824544
Name:VARDO, JONATHAN JOSEPH
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JOSEPH
Last Name:VARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1399 PHILLIPS RD
Mailing Address - Street 2:APARTMENT G80
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-1937
Mailing Address - Country:US
Mailing Address - Phone:508-965-3689
Mailing Address - Fax:
Practice Address - Street 1:1 FATHER DEVALLES BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1511
Practice Address - Country:US
Practice Address - Phone:508-673-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8961225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant