Provider Demographics
NPI:1750633590
Name:LIBRADILLA, JEROME
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:
Last Name:LIBRADILLA
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 1:61 BROADWAY RM 2824
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006-2816
Mailing Address - Country:US
Mailing Address - Phone:212-981-1977
Mailing Address - Fax:
Practice Address - Street 1:61 BROADWAY RM 2824
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-2816
Practice Address - Country:US
Practice Address - Phone:212-981-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist