Provider Demographics
NPI:1407369846
Name:CORONEL, BLADDYMIR
Entity Type:Individual
Prefix:
First Name:BLADDYMIR
Middle Name:
Last Name:CORONEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BLADDYMIR
Other - Middle Name:
Other - Last Name:CORONEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:258 ANDREW PL
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07403-1524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:258 ANDREW PL
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:NJ
Practice Address - Zip Code:07403-1524
Practice Address - Country:US
Practice Address - Phone:201-704-8134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA00467400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist