Provider Demographics
NPI:1821272659
Name:MASSOPUST, ROBERT A (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:MASSOPUST
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:721 W LAKE ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-2035
Mailing Address - Country:US
Mailing Address - Phone:630-543-7450
Mailing Address - Fax:630-543-7475
Practice Address - Street 1:721 W LAKE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2035
Practice Address - Country:US
Practice Address - Phone:630-543-7450
Practice Address - Fax:630-543-7475
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070010142225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070010142OtherILLINOIS LICENSE