Provider Demographics
NPI:1659592061
Name:SALCEDO, MARK MONTESCLAROS (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:MONTESCLAROS
Last Name:SALCEDO
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 1:12 WITTENBERG DR
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-1215
Mailing Address - Country:US
Mailing Address - Phone:646-338-4062
Mailing Address - Fax:
Practice Address - Street 1:12 WITTENBERG DR
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863-1215
Practice Address - Country:US
Practice Address - Phone:646-338-4062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026044-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY026044-1OtherLICENSE#