Provider Demographics
NPI:1598766024
Name:MOTTILLO, MARK A (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:MOTTILLO
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 1:125 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354-2517
Mailing Address - Country:US
Mailing Address - Phone:814-827-0354
Mailing Address - Fax:814-827-0352
Practice Address - Street 1:4247 W RIDGE RD STE 104
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1746
Practice Address - Country:US
Practice Address - Phone:814-833-7249
Practice Address - Fax:814-838-2661
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007800L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAV0843BOtherUPMC
PA85873OtherHIGHMARK
PA001689240005Medicaid
PA5622458OtherFIRST HEALTH
PA021111Medicare PIN