Provider Demographics
NPI:1700384328
Name:OBATE, KEVIN PONCE (RPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:PONCE
Last Name:OBATE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2685 UNIVERSITY AVE APT 44A
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3360
Mailing Address - Country:US
Mailing Address - Phone:917-861-7610
Mailing Address - Fax:
Practice Address - Street 1:1975 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453
Practice Address - Country:US
Practice Address - Phone:718-618-0052
Practice Address - Fax:718-618-0100
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist