Provider Demographics
NPI:1558673657
Name:CORDOVA, REMAR GALLEGO (PT)
Entity Type:Individual
Prefix:
First Name:REMAR
Middle Name:GALLEGO
Last Name:CORDOVA
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 1:14118 78TH AVE
Mailing Address - Street 2:APT. 2D
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3377
Mailing Address - Country:US
Mailing Address - Phone:347-730-7448
Mailing Address - Fax:
Practice Address - Street 1:229 E 21ST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6433
Practice Address - Country:US
Practice Address - Phone:212-473-3703
Practice Address - Fax:212-473-3709
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031065-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist