Provider Demographics
NPI:1760628002
Name:DISISTO, CHRISTOPHER MICHAEL (PT DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:DISISTO
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:584 N STATE RD
Practice Address - Street 2:
Practice Address - City:BRIARCLIFF MANOR
Practice Address - State:NY
Practice Address - Zip Code:10510-1522
Practice Address - Country:US
Practice Address - Phone:914-762-2222
Practice Address - Fax:914-762-2549
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030746-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist