Provider Demographics
NPI:1578566022
Name:MULDER, MARCO FRANK (PT)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:FRANK
Last Name:MULDER
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 1:97 RIVER HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-1754
Mailing Address - Country:US
Mailing Address - Phone:631-258-0863
Mailing Address - Fax:
Practice Address - Street 1:97 RIVER HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1754
Practice Address - Country:US
Practice Address - Phone:631-258-0863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-28
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ96251Medicare PIN