Provider Demographics
NPI:1689207904
Name:MAGISTRADO, VIC JASON B
Entity Type:Individual
Prefix:
First Name:VIC JASON
Middle Name:B
Last Name:MAGISTRADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 NORTH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-2149
Mailing Address - Country:US
Mailing Address - Phone:718-644-1464
Mailing Address - Fax:
Practice Address - Street 1:1087 MACE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-4416
Practice Address - Country:US
Practice Address - Phone:718-644-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017215225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherPART B