Provider Demographics
NPI:1417253006
Name:MASSAK, MINA (PT)
Entity Type:Individual
Prefix:MR
First Name:MINA
Middle Name:
Last Name:MASSAK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 521
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08862-0521
Mailing Address - Country:US
Mailing Address - Phone:732-641-3620
Mailing Address - Fax:732-826-3613
Practice Address - Street 1:155 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:HOPELAWN
Practice Address - State:NJ
Practice Address - Zip Code:08861-4133
Practice Address - Country:US
Practice Address - Phone:732-641-3620
Practice Address - Fax:732-826-3613
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01385300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ207820YWEZMedicare PIN