Provider Demographics
NPI:1649557547
Name:SAN JOSE, MARK NOEL VILLARAMA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARK NOEL
Middle Name:VILLARAMA
Last Name:SAN JOSE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CARNEGIE PLZ
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1000
Mailing Address - Country:US
Mailing Address - Phone:877-407-3422
Mailing Address - Fax:877-407-4329
Practice Address - Street 1:1833 W PLAZA DR
Practice Address - Street 2:FOX REHAB VIRGINIA REGIONAL OFFICE
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6365
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006077225X00000X
MD06222225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist