Provider Demographics
NPI:1326698341
Name:EDILLON, NEIL TIMOTHY PONCE (PT)
Entity Type:Individual
Prefix:
First Name:NEIL TIMOTHY
Middle Name:PONCE
Last Name:EDILLON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:131 MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3341
Mailing Address - Country:US
Mailing Address - Phone:410-535-6975
Mailing Address - Fax:410-535-6915
Practice Address - Street 1:4000 MITCHELLVILLE RD STE A414
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3142
Practice Address - Country:US
Practice Address - Phone:301-860-0985
Practice Address - Fax:301-860-0978
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MD27547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist