Provider Demographics
NPI:1437356987
Name:SAMODULSKI, JULIAN THOMAS (DPT)
Entity Type:Individual
Prefix:MR
First Name:JULIAN
Middle Name:THOMAS
Last Name:SAMODULSKI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 WEEKS AVE
Mailing Address - Street 2:
Mailing Address - City:OYSTER BAY
Mailing Address - State:NY
Mailing Address - Zip Code:11771-2308
Mailing Address - Country:US
Mailing Address - Phone:516-340-9501
Mailing Address - Fax:516-340-9501
Practice Address - Street 1:68 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-2284
Practice Address - Country:US
Practice Address - Phone:516-340-9501
Practice Address - Fax:516-340-9501
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028654225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03362714Medicaid
NYG400010166Medicare PIN