Provider Demographics
NPI:1568454809
Name:PETINO, CHRISTIAN J (MA, MS, PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:CHRISTIAN
Middle Name:J
Last Name:PETINO
Suffix:
Gender:M
Credentials:MA, MS, PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NETCONG
Mailing Address - State:NJ
Mailing Address - Zip Code:07857-1111
Mailing Address - Country:US
Mailing Address - Phone:973-448-1800
Mailing Address - Fax:
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:
Practice Address - City:NETCONG
Practice Address - State:NJ
Practice Address - Zip Code:07857-1111
Practice Address - Country:US
Practice Address - Phone:973-448-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA07139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P77580Medicare UPIN
066072Medicare ID - Type Unspecified