Provider Demographics
NPI:1578108080
Name:MISAYLIDI, JAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:MISAYLIDI
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 1:121 ADAMECS WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08879-3444
Mailing Address - Country:US
Mailing Address - Phone:347-476-1617
Mailing Address - Fax:
Practice Address - Street 1:962 MANOR RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-7041
Practice Address - Country:US
Practice Address - Phone:718-982-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041849-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist