Provider Demographics
NPI:1558973529
Name:JANDONGAN, RICO M (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:RICO
Middle Name:M
Last Name:JANDONGAN
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CHARLTON AVE
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604-2306
Mailing Address - Country:US
Mailing Address - Phone:201-724-7441
Mailing Address - Fax:
Practice Address - Street 1:14008 SANFORD AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2683
Practice Address - Country:US
Practice Address - Phone:718-445-3888
Practice Address - Fax:516-665-0001
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019513208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty