Provider Demographics
NPI:1326115635
Name:FORMOLOW, ALEXANDER (DPT)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:FORMOLOW
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 BEGONIA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-4176
Mailing Address - Country:US
Mailing Address - Phone:732-939-1360
Mailing Address - Fax:
Practice Address - Street 1:220 SUNSET RD
Practice Address - Street 2:SUITE 5A AND B
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1126
Practice Address - Country:US
Practice Address - Phone:609-835-4801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01092200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ087119Medicare ID - Type Unspecified