Provider Demographics
NPI:1740612548
Name:ROBERTO, MICHAEL COSTANZO (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:COSTANZO
Last Name:ROBERTO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:740 MARNE HWY
Mailing Address - Street 2:STE 203
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3127
Mailing Address - Country:US
Mailing Address - Phone:856-914-1400
Mailing Address - Fax:856-234-3014
Practice Address - Street 1:740 MARNE HWY
Practice Address - Street 2:STE 203
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3127
Practice Address - Country:US
Practice Address - Phone:856-914-1400
Practice Address - Fax:856-234-3014
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-02
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01535700225100000X
PAPT0230712251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic