Provider Demographics
NPI:1538331442
Name:VITUG, REY MOISES FAJARDO (PTA)
Entity Type:Individual
Prefix:MR
First Name:REY MOISES
Middle Name:FAJARDO
Last Name:VITUG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 TOWERS ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-1004
Mailing Address - Country:US
Mailing Address - Phone:201-333-8987
Mailing Address - Fax:
Practice Address - Street 1:560 BERKELEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-2109
Practice Address - Country:US
Practice Address - Phone:973-672-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00194900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant