Provider Demographics
NPI:1578761169
Name:RITZEL, MARK JOSEPH (PTA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:RITZEL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NY
Mailing Address - Zip Code:13416-1818
Mailing Address - Country:US
Mailing Address - Phone:315-891-3156
Mailing Address - Fax:
Practice Address - Street 1:690 W GERMAN ST
Practice Address - Street 2:
Practice Address - City:HERKIMER
Practice Address - State:NY
Practice Address - Zip Code:13350-2135
Practice Address - Country:US
Practice Address - Phone:315-866-3330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004119-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant