Provider Demographics
NPI:1619032059
Name:DESIDERIO, RALPH (MSPT)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:
Last Name:DESIDERIO
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-1832
Mailing Address - Country:US
Mailing Address - Phone:732-615-9622
Mailing Address - Fax:732-615-9624
Practice Address - Street 1:1702 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-1832
Practice Address - Country:US
Practice Address - Phone:732-615-9622
Practice Address - Fax:732-615-9624
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA008842002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084984TEDMedicare ID - Type UnspecifiedRENDERING NUMBER