Provider Demographics
NPI:1619902897
Name:DONOGHUE, MICHAEL JOHN (PT ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:DONOGHUE
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CUTTS DR
Mailing Address - Street 2:
Mailing Address - City:TABERNACLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08088-8656
Mailing Address - Country:US
Mailing Address - Phone:609-268-1915
Mailing Address - Fax:
Practice Address - Street 1:1007 MANTUA PIKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3963
Practice Address - Country:US
Practice Address - Phone:856-845-1253
Practice Address - Fax:856-845-3779
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00400900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ035723Medicare ID - Type Unspecified