Provider Demographics
NPI:1518375617
Name:DISHON, KEVIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DISHON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:1255 BROAD ST
Practice Address - Street 2:SUITE 207
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3000
Practice Address - Country:US
Practice Address - Phone:973-893-9300
Practice Address - Fax:973-893-0073
Is Sole Proprietor?:No
Enumeration Date:2014-08-01
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10224225100000X
NJ40QA01703300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist