Provider Demographics
NPI:1609319599
Name:REYNOSO, AUGUSTO (DPT)
Entity Type:Individual
Prefix:DR
First Name:AUGUSTO
Middle Name:
Last Name:REYNOSO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07504-1221
Mailing Address - Country:US
Mailing Address - Phone:973-337-0315
Mailing Address - Fax:
Practice Address - Street 1:414 E 41ST ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-1221
Practice Address - Country:US
Practice Address - Phone:973-337-0315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01706700225100000X
ID2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer