Provider Demographics
NPI:1689739864
Name:MABEZA, ELMER P (RPT)
Entity Type:Individual
Prefix:MR
First Name:ELMER
Middle Name:P
Last Name:MABEZA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:870 WESLEY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1432
Mailing Address - Country:US
Mailing Address - Phone:516-223-8286
Mailing Address - Fax:516-223-8286
Practice Address - Street 1:36 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-665-3714
Practice Address - Fax:631-665-3749
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP1731Medicare PIN