Provider Demographics
NPI:1346314093
Name:GALLUCCI, JOHN ANTHONY JR (MS, ATC, PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:GALLUCCI
Suffix:JR
Gender:M
Credentials:MS, ATC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2994
Mailing Address - Country:US
Mailing Address - Phone:973-669-0078
Mailing Address - Fax:973-669-1113
Practice Address - Street 1:622 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2994
Practice Address - Country:US
Practice Address - Phone:973-669-0078
Practice Address - Fax:973-669-1113
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01172700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY027198-1OtherNY PHYSICAL THERAPY LICENSE
NJQ59614Medicare UPIN
NY027198-1OtherNY PHYSICAL THERAPY LICENSE